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Adaptations of Cognitive Therapy for Depressed Adolescents
CASE STUDY Adaptations of Cognitive Therapy for Depressed Adolescents T.C.R. (CHRIS) WILKES, M.PHIL.,
AND
A. JOHN RUSH, M.D.
Abstract. This paper suggests methods for adapting cognitive therapeutic techniques to the treatment of nonpsychotic depressed adolescents. Adolescents differ from adults in regard to the differential diagnosis of depression, optimal methods to elicit thinking deficits, a need to identify unique modes of communication, management of the therapeutic alliance, and definingthe role of parents in therapy. A proposal for a treatment model of cognitive therapy for this agegroup is presented and illustrated. J. Am. Acad. Child Adolesc. Psychiatry, 1988,27,3:381-386. Key Words: cognitive therapy, adolescents, depression. Treatment focuses on specific cognitive elements of depression using both behavioral and verbal procedures to teach patients to become aware of their views of specific events. Patients learn to monitor and evaluate recurrent patterns of thinking. The evaluation consists of a logical analysis of the validity of automatic thoughts by determining whether or not they are reasonable, rational, or even helpful. This process leads to the development of alternative constructions of dayto-day events through heavy reliance on Socratic dialogue. Techniques used to accomplish this revision in thinking patterns, include the triple column technique. The patient records in one column the feelings experienced in a particular situation. In a second column, he or she records the thoughts that occur in that time situation (automatic thoughts). In the third column, rational responses to these thoughts are recorded. Alternatively, the therapist and patient may collaborate to identify the logical errors in the automatic thoughts and to develop a more realistic response to automatic negative thoughts. Once these core beliefs and basic assumptions are identified, they can then be modified by weighing the advantages and disadvantages and appropriateness of such dysfunctional attitudes. Homework tasks to assess the validity and usefulness of these assumptions are planned and carried out with the objective of developing new alternative assumptions or the judgment to moderate hypervalent assumptions. Cognitive theory of depression states that the various symptoms of the depressive syndrome can be understood in terms of a cognitive shift. Patients interpret their experiences in terms of defeat, desertion, and deprivation and regard themselves as inadequate or defective. They are prone to attribute unpleasant events to deficiencies within themselves-a presumed character defect. There seems no hope for future change. The term cognitive triad refers to negative views held by patients about themselves, their world, and their future. These negative views may maintain or exacerbate symptoms of the depressive syndrome. Two other important areas of cognitive dysfunction in depression have been identified and are referred to as logical systematic errors and dysfunctional attitudes or idiosyncratic schemata, both of which help to explain why certain internal or external events serve to exacerbate negative thinking. Thus, negative thoughts and self-defeating behaviors are not considered to come from a desire to lose or punish oneself but from patients' inability to either conceive or to act upon and carry out other more constructive alternative plans of action. Ex-
Cognitive therapy (CT) with adult depressed outpatients has been well defined and subjected to several outcome trials (e.g., Beck et al., 1985; Blackburn et al., 1981; Murphy et al., 1984; McLean and Hakstian, 1979) (for a review, see Jarrett and Rush, 1985). However, CT with depressed adolescents has. received little attention to date (Bedrosian, 1981), although depressive disorders in this population are common (Hudgens, 1974; King and Pittman, 1969). In adapting CT and techniques for adolescents, the authors have built upon Beck's methods for adult depression (Beck et al., 1979). In order to maintain a focus on a methodology comparable with CT techniques used in adult depression, four adolescents who met DSM-III criteria for major depression were treated. Background CT for depression has been specified and described (Beck et al., 1979) as a short-term psychotherapeutic approach in which patients and therapists work in a collaborative method to accomplish specific objectives. Initially, therapy focuses on symptom reduction; prophylaxis against future depressions is the target of later treatment. Accepted February 3. 1988. Dr. Wilkes is a Consultant Psychiatrist at the Alberta Social and Community Mental Health Services. Lethbridge. Alberta, Canada. and Dr. Rush is Betty Jo Hay Professor of Psychiatry. University of Texas Southwestern Medical Center at Dallas. This research was supported in part by a grant to Dr. Rush (MH38238) from the National Institute ofMental Health and by a Mental Health Clinical Research Center Grant (MH-41115) from NIMH to UTSMCD. A version ofthis paper was presented at the annual meeting ofthe American Society for Adolescent Psychiatry, Dallas, May 1985. The authors express appreciation to Kenneth Z. Altshuler, M.D .. Stanton Sharp Professor and Chairman. Department of Psychiatry. University of Texas Southwestern Medical Center at Dallas and to Professor Robert E. Kendall. Chairman. Department of Psychiatry. University ofEdinburghfor their administrative support, to Mr. David Savage for his secretarial assistance. and to Ivy Blackburn, Ph.D. for her clinical supervision. Special thanks goes to Warren Weinberg, M.D. for his teachings in differentiating neurological and psychiatric disorders in young people and to Mrs. Susan Wilkes for her enduring support. Reprint requests to Dr. Rush. Department ofPsychiatry and Mental Health Clinical Research Center, University of Texas Southwestern Medical Center at Dallas. Kl.900. 5323 Harry Hines Blvd.. Dallas. TX 75235. 0890-8567/88/2703-0381 $2.00/0 © 1988 by the American Acad-
emy of Child and Adolescent Psychiatry. 31'1
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amples of such logical systematic errors in depression include: I. Arbitrary inference-the interpretation of an event in a negative way without consideration of an alternative explanation . Example: "My father did not telephone me last evening, and that proves that he does not really love me." 2. Selective abstraction-taking one fact out of context and drawing a conclusion from it while ignoring contradictory evidence. Example: A young boy visits his divorced father during the weekend and when the father greets unexpected guests, the boy becomes depressed with the thought that his father is much happier around others and that he does not want to be around his son . 3. Overgeneralization-drawing a general conclusion from one isolated incidence. Example: A young girl fails to be chosen to act in the school play; therefore she assumes that she is a worthless actress. 4. Personalization-refers to a patient's tendency to relate external events to themselves. Example: "My parents d ivorced because of my bad behavior." 5. Magnification-distortion of evidence, so that a minor setback is perceived as a major disaster. Example: "The dress I made has a button missing, so it's useless." 6. Minimization-distortion of evidence, so that positive achievements are not recognized. Example: "So what if I get chosen to play on the football team. Any dummy who turns up for practice will be selected. " 7. Absolute or dichotomous thinking-all experiences are placed in one of two opposite categories. Example: Everything is perfect versus everything is terrible. These distorted negative perceptions and their associated logical errors are consequences of hyperactive schemata. The schemata are idiosyncratic, enduring concepts that act as templates, screening, coding, categorizing, and evaluating information. These schemata are frequently inflexible, unspoken general rules, beliefs, or silent assumptions developed from early experiences. They can form the basis for making judgments about a particular situation. Judgments that are based on active schemata are, therefore, distorted to match the individual's self-concept and concept of his or her world. For example, correction from a superior at work may be perceived as, "I am totally worthless." This evaluation (cognition or automatic thought) increases feelings of guilt or sadness. According to the theory, dysfunctional schemata increase a person's vulnerability to depression. They are hypervalent, more active, apparent, and exert more influence during a symptomatic episode of depression, but they become latent with clinical remission. Diagnosis and Conceptualization of Depression Clinical diagnosis may require two to four interviews to assess both the family and the patient. The descriptive diagnosis of depression must be established with specific criteria (e.g., Weinberg et al. (1973» or DSM-III criteria. The severity of symptoms should be measured as well (e.g., Bellevue Inventory for Depression (Petti, 1978». A family history to ascertain the presence of affective disorders, hyperactivity, learning disorders, sociopathy, alcoholism, etc. in first-, second-, and third-degree relatives is important to place the depression in context. During the evaluation, ident ification of each family rnern-
ber's perception of the problem is important, and a review of what methods have already been tried and their results will reveal the interpersonal disputes, as well as familial and individual beliefs about the problem(s). As part of this psychological assessment, coping skills and present social supports are revealed . The Therapeutic Alliance Adolescents seldom seek therapy on their own; the y are urged or forced by their parents. To increase the therapeutic alliance, the therapist should acknowledge their reluctance to attend and collaboratively explore the perceptions such as, "I don't have a problem; it's everyone else." The therapist must establish neutrality both by words and behavior and clarify the role he or she will play. Early on, the therapist should directly address myths commonly held by adolescents such as "Therapy is a punishment," or "The therapist knows what I think and feel without me saying it." An accurate assessment of the problem and development of a plan for possible solutions are the objects oftreatment, and they cannot be achieved without patient cooperation. The patient is appealed to as a critical collaborator in problem solving. Noncompliance with appointments is frequent with adolescents. Adolescents who fail to keep scheduled appointments often later appear at unscheduled times. When this erratic compliance occurs, the therapist explores the patient's perception of the therapist and the appointment-as a vehicle to elucidate the cogniti ve model of emotional disorders. For example, a 16-year-old who missed his second appointment was brought to the following session by his father. A triple column was drawn up by patient and therapist about the missed session. Emotion Fear
Automatic Thought "If I go to see the doctor, he might put me back in the hospital."
Rational Response "I'm coming here to learn how I can be happier at home and school. I would only return to the hospital if I became so depressed that my life was in danger."
This example shows how noncompliance often reflects the patient's thoughts/fears about the therapist and how cognitive techniques can identify and counter them. This procedure is often repeated several times to convince the patient that he selectively attends to observations that confirm his negatively biased notions about the world in which he lives. A close liaison between therapist and family is vital to negate counter-therapeutic parental beliefs/expectations and model problem-solving behavior for the patient. This liaison reduces possible rivalry between therapist and parent(s). The liaison can be strengthened by frequently giving and receiving feedback from the parents, as well as the patient, during the course of therapy. Modes of Communication Adolescents often communicate deep feelings or beliefs in nonverbal ways. The therapist must identify how each patient
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optimally communicates. For example, a 16-year-old boy kept "forgetting" the triple column assignment (Beck et al., 1979) but evidenced no learning disability. His parents complained that he often wrote poems and drew pictures rather than doing school homework. With this knowledge, the therapist discontinued the triple column and requested drawings or poems. Subsequently, the therapist was bombarded with a plethora of poems and pictures. Recurrent themes of boys lost or persecuted by an impersonal and frightening world were obvious. These data helped the therapist and patient enunciate his perception of himself, his world, and his future . Just as in play therapy (Klein, 1963), the adolescent communicates in metaphors. Over several sessions, hypothesis testing with logical analysis was used to gradually revise these views of himself and his parents. Ultimately, he came to see himself as a person who had a talent for poetry and drawing who was valued by his strict parents. As this more realistic perspective developed, new expectations were targeted for future sessions. The spontaneous verbalizations during the sessions are often direct expressions of the negative cognitive triad or dysfunctional beliefs. As such , they can be used in lieu of written homework to elicit automatic thoughts. The 13-yearold who evidenced violent outbursts of anger responded to the therapist: T : You look angry, J. .. . J : I didn 't want to talk to you. All I do is talk. I am here because my parents and that other doctor says I should be here. I want to get out of here as soon as possible. People think that you are mentally sick if you are here. That you are dangerous. People are afraid of us. That's why we are locked up in here like a prison. We don't even get presents here, not like the rest of the wards... .
This outburst from the patient contains a host of multiple negative automatic thoughts about himself, his future, and his environment. This patient saw himself as being different, sick, neglected, and subject to irrational adult coercions. These strongly held notions must be expressed and acknowledged by the therapist before discussion with logical analysis or homework experiments are attempted. Premature confrontation of these ideas risks disruption of the therapeutic alliance . Once automatic thoughts are elicited, they are evaluated and tested as in therapy with adults. However, adolescents, especially younger adolescents, have difficulty with the notion of logical errors, and the y often have a lower capacity for empathy, fewer interpersonal skills, and difficulty with consequential thinking (Kendall et al., 1981). It is often more useful to simply consider alternative ways of perceiving events rather than trying to teach patients how to identify logical errors and to correct them, which requires formal thinking skills. Many adolescents use preoperational or con crete operational Piagetian cognitive skills (Piaget, I977a, b, 1979). Thus, the patient's level of cognitive development dictates how and which cognitive techniques are optimal. The more patients display a capacity for consequential thinking, or an ability to generate some alternative views, the less modification of adult cognitive techniques is needed. Children with learning difficulties can use cognitive-behavioral methods if their optimal mode of communication is
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used. To illustrate, consider the adult therapeutic technique of point-counterpoint (Burns , 1980, chapter 10) with a 13year-old mildly dyslexic boy, who was particularly enthusiastic about acting. He complained about failing to win the school prize. The therapist offered to role-playa mean school friend while the patient was to use answers and arguments just rehearsed . T: You're no good. J. J: What do you mean ? T: You didn't win a prize. J: Not everybody can win a prize. Besides, I came in second. T: That's no good, you've been second before. It's no good unless you win. J: I still enjoy being with my friends and a teacher has to award people's efforts as well. Just because you don't win. does not mean that you are no good. T: Okay, you've convinced me.
While poorly attentive to written information because of dyslexia, he easily role-played and used verbal memory. In this case, the triple column technique was ineffective. Dichotomous/Exaggerated Thinking Depressed adolescents , like adults, frequently demonstrate constricted thinking. This is exemplified by the use of words such as "always, never, it's all over, and it's too late." However, adolescents, unlike adults , may have the additional handicap of a restricted vocabulary. Therefore, the therapist teaches that there is a range or continuum of alternatives, thus challenging the dichotomous thinking style and facilitating alternative perceptions. To illustrate, a 13-year-old boy came to his first session after just I week back at school following hospitalization. He said everything was "going terribly." To clarify the meaning, the therapist drew a line representing a continuum-the best to the worst school situations. With the patient, the therapist defined the worst possible scenario as being tearful and depressed, arguing with everybody , being punished at school , trying hard and not passing any tests, not participating in extracurricular activities, and being expelled from elective subjects even though his parents were helping him . The best scenario was most homework done in class without parental help, getting almost straight As, participating in all extracurricular activities , being moved out of remedial class, and spending more time with school friends. The patient used a pencil to indicate where he fell on this continuum at the time of hospitalization. He chose very close to the worst point . Next, he marked his location for the past week-about 50%. During this exercise, the patient's mood markedl y improved. At the end, he spontaneously noted that things "weren't all that bad." To provide practi ce exercise to challenge his dichotomous thinking outside therapy, the therapist and patient developed a vocabulary of moods ranging from 0 to 10 (O-"the pits," 2.5-fair, 5.0-okay, 7.5-good, and 10.0-great), which he applied to various situations. When increasing school difficulties became apparent and the patient had stated, "I really don't like the teachers," a specific target had been identified and, thus , the therapeutic progress was facilitated.
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Adolescents often wrestle with the problem of omnipotence. One 16-year-old remarked that he felt invulnerable, stating "I can do anything." The day before, he had consumed a pint of whiskey, assuming he could handle anything. He got drunk and was sent hom from school. He was very despondent and considered himself weak because he could not drink that amount and remain sober. This dichotomous thinking was challenged with a continuum of intoxication from a to 10: no effect-a, through tipsy or happy, laughing with poor coordination, nausea and slurred speech, to comatose-IO. A brief educational discussion ensued about blood alcohol levels and liver metabolism as factors relevant to alcohol tolerance that are unrelated to the idea of toughness. This discussion indirectly confronted his idea of omnipotence in a nonjudgmental fashion. Suicidal Thinking Beck et al. (1979) wrote extensively on the management of suicidal tendencies, using the pros and cons technique applied to the reasons for living. However, in adolescents, suicide deserves special reference, not only because it is associated with an alarming increase in the past 10 years but also because it is a common hospital emergency, especially in the 15- to 19-year old, impulsive and drug-abusive male. Adolescents, like some adults, may not fully comprehend the meaning of suicide. However, unlike adults, adolescents also struggle with issues ofa "new" emerging identity, impulse control, cognitive distortion, and cognitive deficits, such as dichotomous thinking and lack of consequential thinking. They are therefore, more likely to act out morbid preoccupations and perceive their death in a different reality than do adults. For instance, one 16-year-old mentioned that he wanted to commit suicide to "look tough" and gain respect from his peers. He didn't recognize that (I) his friends might not regard suicide as "being tough," and (2) he would neither see their reactions nor experience their personal praise. The downward arrow technique (Bums, 1980) was used to operationalize the meaning of "being tough." To the patient, being tough meant "You're a winner. You have a lot of friends." Therapy focused on other ways to achieve these desires. Behavioral goals (e.g., playing basketball, running, and lifting weights) were identified as more likely to succeed than being dead to achieve these objectives. Note that the idea of suicide was accepted but revised as being both unrealistic and ineffective in pursuit of his actual goal. A later session focused on the adolescent's desire to run away. In this session, the pros and cons technique was used (Beck et al., 1979). Cons included: (I) "I don't want to be a nuisance to my parents;" (2) "I don't want to lose all my friends;" and (3) "I'd have no support or place to stay." Pros included: (I) "Getting away from church;" and (2) "I'd have more freedom and away from myoid self." Thereafter, the patient still wanted to run away, but the therapist and patient agreed that he would not do anything until he had reviewed his plans in the next session. As homework, he was to find out how much money he would need and where he would stay. This assignment led him to develop an alternate planto stay at home because he wanted a college education. Leaving home would interrupt his educational ambitions. Therapy then focused on coping with specific family rules
that he found uncomfortable or inconvenient. He obviously had to accept some rules to achieve his desires and family support. The timing of this discussion was crucial in this case. Guided discovery facilitated the acceptance of the idea, but such conclusions cannot be forced on unwilling, stubborn adolescents. Parental Beliefs/Perceptions Parental perceptions/beliefs can either facilitate or obstruct therapy, as illustrated by the following case. J., a 13-year-old boy, was referred by his family doctor for depression. Chronic parental discord with a recent parental separation was noted. The father saw him on alternate weekends. After these visits, J. became very upset and despondent upon returning home, which infuriated the mother. She thought J. was more attached to the father than to her. Meanwhile, J. complained that his father's phone calls were intermittent and unpredictable. His mother frequently telephoned his father to urge that he call J., who was still upset after his father's visit. This operant system rewarded the undesired behavior (being upset after returning from his father's). Furthermore, when his father said he would call, he often did not, which left J. plummeting into depression. The therapist helped identify automatic thoughts that preceded increased sadness and anger when J.'s father failed to call. Logical analysis was used to counter these thoughts, with some improvement. The problem was not resolved, however, until the therapist engaged the family in disrupting the above operant reward system. To accomplish this, the therapist discussed with and corrected each parent's expectations that the other was responsible for helping J. adjust to the separation. In addition, J.'s conflict with his mother was the focus of a joint session. A series of questions about her anger toward J. enabled her to say that she saw J. as ruling her life. When he became sad, he was often irritable and uncooperative, not helping with any chores. She perceived this behavior as being "just like his dad." This view reduced her effectiveness as a parent as it led to her struggling not to "give into" J.'s bad behavior (otherwise he would end up just like his dad). J. reciprocated with thoughts of, "She never asks me to do things; she just expects me to know." He felt helpless and angry. During this emotional session, J. was shouting, "She is my problem." The therapist used this exchange to point out the dangers of mind reading. While each was invested in doing the right thing for the other, without clarifying what each was thinking, feeling, and expecting of the other, an argument often ensued. The therapist used a behavioral task to facilitate direct communication about specific expectations. He asked J.'s mother to list chores she wanted J. to help with and asked J. to do one chore each day. This task helped her see that her expectations had to be made clear and helped J. feel important and contributory. The joint interview revealed hidden expectations and beliefs that may have less likely surfaced during individual sessions. Enmeshment in the Family Depressed adolescents often have an enmeshed family pattern (Minuchin, 1974). The patient and at least one parent tie their moods and behaviors to the other's internal state. To
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intervene in this pattern, we have developed the Dyadic Mood Monitor technique. Consider J., the 14-year-old whose visits with his father were associated with dysphoria. He reported, "I can't go out and enjoy myself if she (the mother) doesn't." To test this notion, he was asked to complete an activity sheet according to a color code. This technique is traditionally used with retarded depressed patients, allowing them to record the Mastery and Pleasure they have experienced throughout the week. However, instead of rating Mastery and Pleasure during the day, mother and son were asked to color in the compartments according to their moods: yellow for good, green for neutral, and red for unhappiness. Both mother and son completed these forms over one weekend and compared them during the next session. The patient had had a good time visiting his father, while the mother was unhappy. In the joint session, exaggeration of the cognitive distortion with humor (Beck et al. 1979) was used to increase objectivity on both parts about their interaction. The Dyadic Mood Monitor technique can also be used with families of children with learning disorders (e.g., dyslexia). For example, a 13-year-old boy with depression and dyslexia had a overly involved 40-year-old mother with emotional lability that she tied to his behavior. Both mother and patient monitored their own moods for I week. Results revealed that even when the mother was sad or preoccupied with the welfare of her son, he was, in fact, quite happy and cheerful, watching television or doing his homework. These data helped to distance herself from her son and become more objective and effective in applying sanctions to his undesirable behaviors. This homework also facilitated a discussion of assumptions and expectations about child rearing with her husband during the session. Her beliefs included "My role is emotional nurturance," and "My husband can't do it." She viewed her husband as quite uninvolved with child rearing which further supported her hypertrophied sense of responsibility to assist her son whenever he was upset. The therapist tried to elicit evidence that she was solely responsible for her son's moods without success. Further discussion revealed that although the father worked many hours, when he was home he often assisted his son in many ways when the son was upset or angry. Furthermore, the father's interventions were rather effective. Reviewing these reports began to challenge the mother's belief and reduce her sense of total responsibility. The homework assignment that followed was to divide overtly and equally between the parents, the task of emotional support for their son. A regular time when father and son were to talk over concerns was prescribed. Subsequently, the mother become more assertive as disciplinarian and confident enough to take a week's holiday break from the family. As the patient improved, the marital discord became more overt. The parents eventually requested joint therapy. Issues of parental roles and meeting each others' expectations became targets of therapy. Cognitive couples therapy was conducted along previously described lines (Rush et al., 1980). Conclusion Traditional short-term cognitive therapy, with its emphasis on setting agendas, listing problem areas, the pursuit of cognition or "ideas" during times of stress, logical analysis of
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cognitions, and scheduled homework assignments, can be used with the depressed adolescent. However, this report identifies three important differences from traditional CT. These include: (I) the therapeutic alliance, (2) the special attention given to the cognitive development of the adolescent, and (3) the involvement of the family of origin in the assessment and treatment process. Adolescents can experience a period of intense negative ambivalence toward authority figures. Therefore, collaboration with an adult therapist can seem challenging and overwhelming. Power struggles can rapidly ensue unless the therapist is aware of the developmental tasks of the adolescent and the frequent coercive process involved in attending therapy. Additionally, the therapist should actively deny omniscience in order to reduce rivalry and envy. The diagnosis of depression further assists the positive, nonjudgmental reframing of hostile behaviors and attitudes in terms of the cognitive changes that occur in depression. Secondly, the cognitive development of the adolescent determines the optimal modes of communication the therapist will use. Action-oriented techniques during the session, concrete behavioral homework tasks, and cognitive restructuring with a cognitive continuum or a Socratic dialogue must be tailored to the cognitive skills of the adolescent. Finally, the adolescent is usually developing in the context of a family that has its own set of beliefs, rules, and expectations. These interact with the adolescent and can perpetuate dysfunctional behavior, emotions, and cognitions. Therefore, the family must be acknowledged and involved in the assessment and treatment process. In practice, this means interviewing the family and adolescent together either at the beginning of an individual session or scheduling joint sessions every second or third visit. This illustrates how CT could be used in conjunction with other treatment modalities. Unfortunately, having established that CT techniques can be adapted to adolescents, it does not prove its efficacy. The efficacy ofCT in this population requires controlled outcome studies. References Beck, A. T., Hollon, S. D.. Young, J. E., Bedrosian, R. C. & Budenz, D. (1985), Treatment of depression with cognitive therapy and amitriptyline. Arch. Gen. Psychiatry. 42: 142-148. - - Rush, A. J., Shaw, B. F. & Emery, G. (1979), Cognitive Therapy for Depression. New York: Guilford Press. Bedrosian, R. C. (1981), The application of cognitive therapy techniques with adolescents. In: New Directions in Cognitive Therapy. A Casebook, ed. G. Emery, S. D. Hollon & R. C. Bedrosian. New York: Guilford Press. Blackburn, I. M., Bishop, S., Glenn, A. I. M., Whalley, L. J. & Christie, J. E. (1981), The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br. J. Psychiatry. 139: 181189. Burns, D. D. (1980), Feeling Good. New York: William Morrow. Hudgens, R. W. (1974), Psychiatric Disorders in Adolescents. Baltimore, Md.: Williams & Wilkins. Jarrett, R. B. & Rush, A. J. (1985), Psychotherapeutic approaches to depression. In: Psychiatry. Vol. I, Chapter 65, ed. J. O. Cavenar. Philadelphia: J. B. Lippincott, and New York: Basic Books. Kendall, P. c., Pelligrino, D. & Urbain, E. S. (1981), Approaches to assessment for cognitive behavioral interventions with children. In: Assessment Strategies for Cognitive-Behavioral Interventions. ed. P. C. Kendall & S. D. Hollon, New York: Academic Press.
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King, L. Pittman, G. D. (1969), A six year follow-up study of sixtyfive adolescent patients: predictive value of presenting clinical picture. Br. J. Psychiatry. 115:1437-1441. Klein, M. (1963). The Psycho-Analysis of Children. Psychoanalysis, London: Hogarth Press. McLean, P. D. & Hakstian, A. R. (1979), Clinical depression: comparative efficacy of outpatient treatments. J. Consult. Clin. Psychol., 47:818-836. Minuchin, S. (1974), Families and Family Therapy. Cambridge, Mass.: Harvard University Press. Murphy, G. E., Simons, A. D., Wetzel, R. D. & Lustman, P. J. (1984), Cognitive therapy and pharmacotherapy. Arch. Gen. Psychiatry. 41:33-4 L Petti, T. A. (1978), Depression in hospitalized child psychiatry pa-
tients: approaches to measuring depression. J. Am. Acad. Child Psychiatry. 17:49-59. Piaget, J. (l977a), The Origin of Intelligence in the Child. London: Penguin Books. - - (1977b), The Moral Judgment of the Child. London: Penguin Books. - - (1979), Piaget's theory. In: Carmichael's Manual of Child Psychology, Vol. I, ed. P. H. Mussen. New York: Wiley. Rush, A. J., Shaw, B. F. & Khatami, M. (1980), Cognitive therapy of depression. Utilizing the couples system. Cognitive Therapy Research. 4: 103-113. Weinberg, W. A., Rutman, J., Sullivan, L., Penick, E. C. & Dietz, S. G. (1973), Depression in children referred to an educational diagnostic center: diagnosis and treatment. J. Pediatr., 83: 1065-1073.
AND
A. JOHN RUSH, M.D.
Abstract. This paper suggests methods for adapting cognitive therapeutic techniques to the treatment of nonpsychotic depressed adolescents. Adolescents differ from adults in regard to the differential diagnosis of depression, optimal methods to elicit thinking deficits, a need to identify unique modes of communication, management of the therapeutic alliance, and definingthe role of parents in therapy. A proposal for a treatment model of cognitive therapy for this agegroup is presented and illustrated. J. Am. Acad. Child Adolesc. Psychiatry, 1988,27,3:381-386. Key Words: cognitive therapy, adolescents, depression. Treatment focuses on specific cognitive elements of depression using both behavioral and verbal procedures to teach patients to become aware of their views of specific events. Patients learn to monitor and evaluate recurrent patterns of thinking. The evaluation consists of a logical analysis of the validity of automatic thoughts by determining whether or not they are reasonable, rational, or even helpful. This process leads to the development of alternative constructions of dayto-day events through heavy reliance on Socratic dialogue. Techniques used to accomplish this revision in thinking patterns, include the triple column technique. The patient records in one column the feelings experienced in a particular situation. In a second column, he or she records the thoughts that occur in that time situation (automatic thoughts). In the third column, rational responses to these thoughts are recorded. Alternatively, the therapist and patient may collaborate to identify the logical errors in the automatic thoughts and to develop a more realistic response to automatic negative thoughts. Once these core beliefs and basic assumptions are identified, they can then be modified by weighing the advantages and disadvantages and appropriateness of such dysfunctional attitudes. Homework tasks to assess the validity and usefulness of these assumptions are planned and carried out with the objective of developing new alternative assumptions or the judgment to moderate hypervalent assumptions. Cognitive theory of depression states that the various symptoms of the depressive syndrome can be understood in terms of a cognitive shift. Patients interpret their experiences in terms of defeat, desertion, and deprivation and regard themselves as inadequate or defective. They are prone to attribute unpleasant events to deficiencies within themselves-a presumed character defect. There seems no hope for future change. The term cognitive triad refers to negative views held by patients about themselves, their world, and their future. These negative views may maintain or exacerbate symptoms of the depressive syndrome. Two other important areas of cognitive dysfunction in depression have been identified and are referred to as logical systematic errors and dysfunctional attitudes or idiosyncratic schemata, both of which help to explain why certain internal or external events serve to exacerbate negative thinking. Thus, negative thoughts and self-defeating behaviors are not considered to come from a desire to lose or punish oneself but from patients' inability to either conceive or to act upon and carry out other more constructive alternative plans of action. Ex-
Cognitive therapy (CT) with adult depressed outpatients has been well defined and subjected to several outcome trials (e.g., Beck et al., 1985; Blackburn et al., 1981; Murphy et al., 1984; McLean and Hakstian, 1979) (for a review, see Jarrett and Rush, 1985). However, CT with depressed adolescents has. received little attention to date (Bedrosian, 1981), although depressive disorders in this population are common (Hudgens, 1974; King and Pittman, 1969). In adapting CT and techniques for adolescents, the authors have built upon Beck's methods for adult depression (Beck et al., 1979). In order to maintain a focus on a methodology comparable with CT techniques used in adult depression, four adolescents who met DSM-III criteria for major depression were treated. Background CT for depression has been specified and described (Beck et al., 1979) as a short-term psychotherapeutic approach in which patients and therapists work in a collaborative method to accomplish specific objectives. Initially, therapy focuses on symptom reduction; prophylaxis against future depressions is the target of later treatment. Accepted February 3. 1988. Dr. Wilkes is a Consultant Psychiatrist at the Alberta Social and Community Mental Health Services. Lethbridge. Alberta, Canada. and Dr. Rush is Betty Jo Hay Professor of Psychiatry. University of Texas Southwestern Medical Center at Dallas. This research was supported in part by a grant to Dr. Rush (MH38238) from the National Institute ofMental Health and by a Mental Health Clinical Research Center Grant (MH-41115) from NIMH to UTSMCD. A version ofthis paper was presented at the annual meeting ofthe American Society for Adolescent Psychiatry, Dallas, May 1985. The authors express appreciation to Kenneth Z. Altshuler, M.D .. Stanton Sharp Professor and Chairman. Department of Psychiatry. University of Texas Southwestern Medical Center at Dallas and to Professor Robert E. Kendall. Chairman. Department of Psychiatry. University ofEdinburghfor their administrative support, to Mr. David Savage for his secretarial assistance. and to Ivy Blackburn, Ph.D. for her clinical supervision. Special thanks goes to Warren Weinberg, M.D. for his teachings in differentiating neurological and psychiatric disorders in young people and to Mrs. Susan Wilkes for her enduring support. Reprint requests to Dr. Rush. Department ofPsychiatry and Mental Health Clinical Research Center, University of Texas Southwestern Medical Center at Dallas. Kl.900. 5323 Harry Hines Blvd.. Dallas. TX 75235. 0890-8567/88/2703-0381 $2.00/0 © 1988 by the American Acad-
emy of Child and Adolescent Psychiatry. 31'1
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amples of such logical systematic errors in depression include: I. Arbitrary inference-the interpretation of an event in a negative way without consideration of an alternative explanation . Example: "My father did not telephone me last evening, and that proves that he does not really love me." 2. Selective abstraction-taking one fact out of context and drawing a conclusion from it while ignoring contradictory evidence. Example: A young boy visits his divorced father during the weekend and when the father greets unexpected guests, the boy becomes depressed with the thought that his father is much happier around others and that he does not want to be around his son . 3. Overgeneralization-drawing a general conclusion from one isolated incidence. Example: A young girl fails to be chosen to act in the school play; therefore she assumes that she is a worthless actress. 4. Personalization-refers to a patient's tendency to relate external events to themselves. Example: "My parents d ivorced because of my bad behavior." 5. Magnification-distortion of evidence, so that a minor setback is perceived as a major disaster. Example: "The dress I made has a button missing, so it's useless." 6. Minimization-distortion of evidence, so that positive achievements are not recognized. Example: "So what if I get chosen to play on the football team. Any dummy who turns up for practice will be selected. " 7. Absolute or dichotomous thinking-all experiences are placed in one of two opposite categories. Example: Everything is perfect versus everything is terrible. These distorted negative perceptions and their associated logical errors are consequences of hyperactive schemata. The schemata are idiosyncratic, enduring concepts that act as templates, screening, coding, categorizing, and evaluating information. These schemata are frequently inflexible, unspoken general rules, beliefs, or silent assumptions developed from early experiences. They can form the basis for making judgments about a particular situation. Judgments that are based on active schemata are, therefore, distorted to match the individual's self-concept and concept of his or her world. For example, correction from a superior at work may be perceived as, "I am totally worthless." This evaluation (cognition or automatic thought) increases feelings of guilt or sadness. According to the theory, dysfunctional schemata increase a person's vulnerability to depression. They are hypervalent, more active, apparent, and exert more influence during a symptomatic episode of depression, but they become latent with clinical remission. Diagnosis and Conceptualization of Depression Clinical diagnosis may require two to four interviews to assess both the family and the patient. The descriptive diagnosis of depression must be established with specific criteria (e.g., Weinberg et al. (1973» or DSM-III criteria. The severity of symptoms should be measured as well (e.g., Bellevue Inventory for Depression (Petti, 1978». A family history to ascertain the presence of affective disorders, hyperactivity, learning disorders, sociopathy, alcoholism, etc. in first-, second-, and third-degree relatives is important to place the depression in context. During the evaluation, ident ification of each family rnern-
ber's perception of the problem is important, and a review of what methods have already been tried and their results will reveal the interpersonal disputes, as well as familial and individual beliefs about the problem(s). As part of this psychological assessment, coping skills and present social supports are revealed . The Therapeutic Alliance Adolescents seldom seek therapy on their own; the y are urged or forced by their parents. To increase the therapeutic alliance, the therapist should acknowledge their reluctance to attend and collaboratively explore the perceptions such as, "I don't have a problem; it's everyone else." The therapist must establish neutrality both by words and behavior and clarify the role he or she will play. Early on, the therapist should directly address myths commonly held by adolescents such as "Therapy is a punishment," or "The therapist knows what I think and feel without me saying it." An accurate assessment of the problem and development of a plan for possible solutions are the objects oftreatment, and they cannot be achieved without patient cooperation. The patient is appealed to as a critical collaborator in problem solving. Noncompliance with appointments is frequent with adolescents. Adolescents who fail to keep scheduled appointments often later appear at unscheduled times. When this erratic compliance occurs, the therapist explores the patient's perception of the therapist and the appointment-as a vehicle to elucidate the cogniti ve model of emotional disorders. For example, a 16-year-old who missed his second appointment was brought to the following session by his father. A triple column was drawn up by patient and therapist about the missed session. Emotion Fear
Automatic Thought "If I go to see the doctor, he might put me back in the hospital."
Rational Response "I'm coming here to learn how I can be happier at home and school. I would only return to the hospital if I became so depressed that my life was in danger."
This example shows how noncompliance often reflects the patient's thoughts/fears about the therapist and how cognitive techniques can identify and counter them. This procedure is often repeated several times to convince the patient that he selectively attends to observations that confirm his negatively biased notions about the world in which he lives. A close liaison between therapist and family is vital to negate counter-therapeutic parental beliefs/expectations and model problem-solving behavior for the patient. This liaison reduces possible rivalry between therapist and parent(s). The liaison can be strengthened by frequently giving and receiving feedback from the parents, as well as the patient, during the course of therapy. Modes of Communication Adolescents often communicate deep feelings or beliefs in nonverbal ways. The therapist must identify how each patient
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optimally communicates. For example, a 16-year-old boy kept "forgetting" the triple column assignment (Beck et al., 1979) but evidenced no learning disability. His parents complained that he often wrote poems and drew pictures rather than doing school homework. With this knowledge, the therapist discontinued the triple column and requested drawings or poems. Subsequently, the therapist was bombarded with a plethora of poems and pictures. Recurrent themes of boys lost or persecuted by an impersonal and frightening world were obvious. These data helped the therapist and patient enunciate his perception of himself, his world, and his future . Just as in play therapy (Klein, 1963), the adolescent communicates in metaphors. Over several sessions, hypothesis testing with logical analysis was used to gradually revise these views of himself and his parents. Ultimately, he came to see himself as a person who had a talent for poetry and drawing who was valued by his strict parents. As this more realistic perspective developed, new expectations were targeted for future sessions. The spontaneous verbalizations during the sessions are often direct expressions of the negative cognitive triad or dysfunctional beliefs. As such , they can be used in lieu of written homework to elicit automatic thoughts. The 13-yearold who evidenced violent outbursts of anger responded to the therapist: T : You look angry, J. .. . J : I didn 't want to talk to you. All I do is talk. I am here because my parents and that other doctor says I should be here. I want to get out of here as soon as possible. People think that you are mentally sick if you are here. That you are dangerous. People are afraid of us. That's why we are locked up in here like a prison. We don't even get presents here, not like the rest of the wards... .
This outburst from the patient contains a host of multiple negative automatic thoughts about himself, his future, and his environment. This patient saw himself as being different, sick, neglected, and subject to irrational adult coercions. These strongly held notions must be expressed and acknowledged by the therapist before discussion with logical analysis or homework experiments are attempted. Premature confrontation of these ideas risks disruption of the therapeutic alliance . Once automatic thoughts are elicited, they are evaluated and tested as in therapy with adults. However, adolescents, especially younger adolescents, have difficulty with the notion of logical errors, and the y often have a lower capacity for empathy, fewer interpersonal skills, and difficulty with consequential thinking (Kendall et al., 1981). It is often more useful to simply consider alternative ways of perceiving events rather than trying to teach patients how to identify logical errors and to correct them, which requires formal thinking skills. Many adolescents use preoperational or con crete operational Piagetian cognitive skills (Piaget, I977a, b, 1979). Thus, the patient's level of cognitive development dictates how and which cognitive techniques are optimal. The more patients display a capacity for consequential thinking, or an ability to generate some alternative views, the less modification of adult cognitive techniques is needed. Children with learning difficulties can use cognitive-behavioral methods if their optimal mode of communication is
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used. To illustrate, consider the adult therapeutic technique of point-counterpoint (Burns , 1980, chapter 10) with a 13year-old mildly dyslexic boy, who was particularly enthusiastic about acting. He complained about failing to win the school prize. The therapist offered to role-playa mean school friend while the patient was to use answers and arguments just rehearsed . T: You're no good. J. J: What do you mean ? T: You didn't win a prize. J: Not everybody can win a prize. Besides, I came in second. T: That's no good, you've been second before. It's no good unless you win. J: I still enjoy being with my friends and a teacher has to award people's efforts as well. Just because you don't win. does not mean that you are no good. T: Okay, you've convinced me.
While poorly attentive to written information because of dyslexia, he easily role-played and used verbal memory. In this case, the triple column technique was ineffective. Dichotomous/Exaggerated Thinking Depressed adolescents , like adults, frequently demonstrate constricted thinking. This is exemplified by the use of words such as "always, never, it's all over, and it's too late." However, adolescents, unlike adults , may have the additional handicap of a restricted vocabulary. Therefore, the therapist teaches that there is a range or continuum of alternatives, thus challenging the dichotomous thinking style and facilitating alternative perceptions. To illustrate, a 13-year-old boy came to his first session after just I week back at school following hospitalization. He said everything was "going terribly." To clarify the meaning, the therapist drew a line representing a continuum-the best to the worst school situations. With the patient, the therapist defined the worst possible scenario as being tearful and depressed, arguing with everybody , being punished at school , trying hard and not passing any tests, not participating in extracurricular activities, and being expelled from elective subjects even though his parents were helping him . The best scenario was most homework done in class without parental help, getting almost straight As, participating in all extracurricular activities , being moved out of remedial class, and spending more time with school friends. The patient used a pencil to indicate where he fell on this continuum at the time of hospitalization. He chose very close to the worst point . Next, he marked his location for the past week-about 50%. During this exercise, the patient's mood markedl y improved. At the end, he spontaneously noted that things "weren't all that bad." To provide practi ce exercise to challenge his dichotomous thinking outside therapy, the therapist and patient developed a vocabulary of moods ranging from 0 to 10 (O-"the pits," 2.5-fair, 5.0-okay, 7.5-good, and 10.0-great), which he applied to various situations. When increasing school difficulties became apparent and the patient had stated, "I really don't like the teachers," a specific target had been identified and, thus , the therapeutic progress was facilitated.
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Adolescents often wrestle with the problem of omnipotence. One 16-year-old remarked that he felt invulnerable, stating "I can do anything." The day before, he had consumed a pint of whiskey, assuming he could handle anything. He got drunk and was sent hom from school. He was very despondent and considered himself weak because he could not drink that amount and remain sober. This dichotomous thinking was challenged with a continuum of intoxication from a to 10: no effect-a, through tipsy or happy, laughing with poor coordination, nausea and slurred speech, to comatose-IO. A brief educational discussion ensued about blood alcohol levels and liver metabolism as factors relevant to alcohol tolerance that are unrelated to the idea of toughness. This discussion indirectly confronted his idea of omnipotence in a nonjudgmental fashion. Suicidal Thinking Beck et al. (1979) wrote extensively on the management of suicidal tendencies, using the pros and cons technique applied to the reasons for living. However, in adolescents, suicide deserves special reference, not only because it is associated with an alarming increase in the past 10 years but also because it is a common hospital emergency, especially in the 15- to 19-year old, impulsive and drug-abusive male. Adolescents, like some adults, may not fully comprehend the meaning of suicide. However, unlike adults, adolescents also struggle with issues ofa "new" emerging identity, impulse control, cognitive distortion, and cognitive deficits, such as dichotomous thinking and lack of consequential thinking. They are therefore, more likely to act out morbid preoccupations and perceive their death in a different reality than do adults. For instance, one 16-year-old mentioned that he wanted to commit suicide to "look tough" and gain respect from his peers. He didn't recognize that (I) his friends might not regard suicide as "being tough," and (2) he would neither see their reactions nor experience their personal praise. The downward arrow technique (Bums, 1980) was used to operationalize the meaning of "being tough." To the patient, being tough meant "You're a winner. You have a lot of friends." Therapy focused on other ways to achieve these desires. Behavioral goals (e.g., playing basketball, running, and lifting weights) were identified as more likely to succeed than being dead to achieve these objectives. Note that the idea of suicide was accepted but revised as being both unrealistic and ineffective in pursuit of his actual goal. A later session focused on the adolescent's desire to run away. In this session, the pros and cons technique was used (Beck et al., 1979). Cons included: (I) "I don't want to be a nuisance to my parents;" (2) "I don't want to lose all my friends;" and (3) "I'd have no support or place to stay." Pros included: (I) "Getting away from church;" and (2) "I'd have more freedom and away from myoid self." Thereafter, the patient still wanted to run away, but the therapist and patient agreed that he would not do anything until he had reviewed his plans in the next session. As homework, he was to find out how much money he would need and where he would stay. This assignment led him to develop an alternate planto stay at home because he wanted a college education. Leaving home would interrupt his educational ambitions. Therapy then focused on coping with specific family rules
that he found uncomfortable or inconvenient. He obviously had to accept some rules to achieve his desires and family support. The timing of this discussion was crucial in this case. Guided discovery facilitated the acceptance of the idea, but such conclusions cannot be forced on unwilling, stubborn adolescents. Parental Beliefs/Perceptions Parental perceptions/beliefs can either facilitate or obstruct therapy, as illustrated by the following case. J., a 13-year-old boy, was referred by his family doctor for depression. Chronic parental discord with a recent parental separation was noted. The father saw him on alternate weekends. After these visits, J. became very upset and despondent upon returning home, which infuriated the mother. She thought J. was more attached to the father than to her. Meanwhile, J. complained that his father's phone calls were intermittent and unpredictable. His mother frequently telephoned his father to urge that he call J., who was still upset after his father's visit. This operant system rewarded the undesired behavior (being upset after returning from his father's). Furthermore, when his father said he would call, he often did not, which left J. plummeting into depression. The therapist helped identify automatic thoughts that preceded increased sadness and anger when J.'s father failed to call. Logical analysis was used to counter these thoughts, with some improvement. The problem was not resolved, however, until the therapist engaged the family in disrupting the above operant reward system. To accomplish this, the therapist discussed with and corrected each parent's expectations that the other was responsible for helping J. adjust to the separation. In addition, J.'s conflict with his mother was the focus of a joint session. A series of questions about her anger toward J. enabled her to say that she saw J. as ruling her life. When he became sad, he was often irritable and uncooperative, not helping with any chores. She perceived this behavior as being "just like his dad." This view reduced her effectiveness as a parent as it led to her struggling not to "give into" J.'s bad behavior (otherwise he would end up just like his dad). J. reciprocated with thoughts of, "She never asks me to do things; she just expects me to know." He felt helpless and angry. During this emotional session, J. was shouting, "She is my problem." The therapist used this exchange to point out the dangers of mind reading. While each was invested in doing the right thing for the other, without clarifying what each was thinking, feeling, and expecting of the other, an argument often ensued. The therapist used a behavioral task to facilitate direct communication about specific expectations. He asked J.'s mother to list chores she wanted J. to help with and asked J. to do one chore each day. This task helped her see that her expectations had to be made clear and helped J. feel important and contributory. The joint interview revealed hidden expectations and beliefs that may have less likely surfaced during individual sessions. Enmeshment in the Family Depressed adolescents often have an enmeshed family pattern (Minuchin, 1974). The patient and at least one parent tie their moods and behaviors to the other's internal state. To
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intervene in this pattern, we have developed the Dyadic Mood Monitor technique. Consider J., the 14-year-old whose visits with his father were associated with dysphoria. He reported, "I can't go out and enjoy myself if she (the mother) doesn't." To test this notion, he was asked to complete an activity sheet according to a color code. This technique is traditionally used with retarded depressed patients, allowing them to record the Mastery and Pleasure they have experienced throughout the week. However, instead of rating Mastery and Pleasure during the day, mother and son were asked to color in the compartments according to their moods: yellow for good, green for neutral, and red for unhappiness. Both mother and son completed these forms over one weekend and compared them during the next session. The patient had had a good time visiting his father, while the mother was unhappy. In the joint session, exaggeration of the cognitive distortion with humor (Beck et al. 1979) was used to increase objectivity on both parts about their interaction. The Dyadic Mood Monitor technique can also be used with families of children with learning disorders (e.g., dyslexia). For example, a 13-year-old boy with depression and dyslexia had a overly involved 40-year-old mother with emotional lability that she tied to his behavior. Both mother and patient monitored their own moods for I week. Results revealed that even when the mother was sad or preoccupied with the welfare of her son, he was, in fact, quite happy and cheerful, watching television or doing his homework. These data helped to distance herself from her son and become more objective and effective in applying sanctions to his undesirable behaviors. This homework also facilitated a discussion of assumptions and expectations about child rearing with her husband during the session. Her beliefs included "My role is emotional nurturance," and "My husband can't do it." She viewed her husband as quite uninvolved with child rearing which further supported her hypertrophied sense of responsibility to assist her son whenever he was upset. The therapist tried to elicit evidence that she was solely responsible for her son's moods without success. Further discussion revealed that although the father worked many hours, when he was home he often assisted his son in many ways when the son was upset or angry. Furthermore, the father's interventions were rather effective. Reviewing these reports began to challenge the mother's belief and reduce her sense of total responsibility. The homework assignment that followed was to divide overtly and equally between the parents, the task of emotional support for their son. A regular time when father and son were to talk over concerns was prescribed. Subsequently, the mother become more assertive as disciplinarian and confident enough to take a week's holiday break from the family. As the patient improved, the marital discord became more overt. The parents eventually requested joint therapy. Issues of parental roles and meeting each others' expectations became targets of therapy. Cognitive couples therapy was conducted along previously described lines (Rush et al., 1980). Conclusion Traditional short-term cognitive therapy, with its emphasis on setting agendas, listing problem areas, the pursuit of cognition or "ideas" during times of stress, logical analysis of
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cognitions, and scheduled homework assignments, can be used with the depressed adolescent. However, this report identifies three important differences from traditional CT. These include: (I) the therapeutic alliance, (2) the special attention given to the cognitive development of the adolescent, and (3) the involvement of the family of origin in the assessment and treatment process. Adolescents can experience a period of intense negative ambivalence toward authority figures. Therefore, collaboration with an adult therapist can seem challenging and overwhelming. Power struggles can rapidly ensue unless the therapist is aware of the developmental tasks of the adolescent and the frequent coercive process involved in attending therapy. Additionally, the therapist should actively deny omniscience in order to reduce rivalry and envy. The diagnosis of depression further assists the positive, nonjudgmental reframing of hostile behaviors and attitudes in terms of the cognitive changes that occur in depression. Secondly, the cognitive development of the adolescent determines the optimal modes of communication the therapist will use. Action-oriented techniques during the session, concrete behavioral homework tasks, and cognitive restructuring with a cognitive continuum or a Socratic dialogue must be tailored to the cognitive skills of the adolescent. Finally, the adolescent is usually developing in the context of a family that has its own set of beliefs, rules, and expectations. These interact with the adolescent and can perpetuate dysfunctional behavior, emotions, and cognitions. Therefore, the family must be acknowledged and involved in the assessment and treatment process. In practice, this means interviewing the family and adolescent together either at the beginning of an individual session or scheduling joint sessions every second or third visit. This illustrates how CT could be used in conjunction with other treatment modalities. Unfortunately, having established that CT techniques can be adapted to adolescents, it does not prove its efficacy. The efficacy ofCT in this population requires controlled outcome studies. References Beck, A. T., Hollon, S. D.. Young, J. E., Bedrosian, R. C. & Budenz, D. (1985), Treatment of depression with cognitive therapy and amitriptyline. Arch. Gen. Psychiatry. 42: 142-148. - - Rush, A. J., Shaw, B. F. & Emery, G. (1979), Cognitive Therapy for Depression. New York: Guilford Press. Bedrosian, R. C. (1981), The application of cognitive therapy techniques with adolescents. In: New Directions in Cognitive Therapy. A Casebook, ed. G. Emery, S. D. Hollon & R. C. Bedrosian. New York: Guilford Press. Blackburn, I. M., Bishop, S., Glenn, A. I. M., Whalley, L. J. & Christie, J. E. (1981), The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br. J. Psychiatry. 139: 181189. Burns, D. D. (1980), Feeling Good. New York: William Morrow. Hudgens, R. W. (1974), Psychiatric Disorders in Adolescents. Baltimore, Md.: Williams & Wilkins. Jarrett, R. B. & Rush, A. J. (1985), Psychotherapeutic approaches to depression. In: Psychiatry. Vol. I, Chapter 65, ed. J. O. Cavenar. Philadelphia: J. B. Lippincott, and New York: Basic Books. Kendall, P. c., Pelligrino, D. & Urbain, E. S. (1981), Approaches to assessment for cognitive behavioral interventions with children. In: Assessment Strategies for Cognitive-Behavioral Interventions. ed. P. C. Kendall & S. D. Hollon, New York: Academic Press.
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King, L. Pittman, G. D. (1969), A six year follow-up study of sixtyfive adolescent patients: predictive value of presenting clinical picture. Br. J. Psychiatry. 115:1437-1441. Klein, M. (1963). The Psycho-Analysis of Children. Psychoanalysis, London: Hogarth Press. McLean, P. D. & Hakstian, A. R. (1979), Clinical depression: comparative efficacy of outpatient treatments. J. Consult. Clin. Psychol., 47:818-836. Minuchin, S. (1974), Families and Family Therapy. Cambridge, Mass.: Harvard University Press. Murphy, G. E., Simons, A. D., Wetzel, R. D. & Lustman, P. J. (1984), Cognitive therapy and pharmacotherapy. Arch. Gen. Psychiatry. 41:33-4 L Petti, T. A. (1978), Depression in hospitalized child psychiatry pa-
tients: approaches to measuring depression. J. Am. Acad. Child Psychiatry. 17:49-59. Piaget, J. (l977a), The Origin of Intelligence in the Child. London: Penguin Books. - - (1977b), The Moral Judgment of the Child. London: Penguin Books. - - (1979), Piaget's theory. In: Carmichael's Manual of Child Psychology, Vol. I, ed. P. H. Mussen. New York: Wiley. Rush, A. J., Shaw, B. F. & Khatami, M. (1980), Cognitive therapy of depression. Utilizing the couples system. Cognitive Therapy Research. 4: 103-113. Weinberg, W. A., Rutman, J., Sullivan, L., Penick, E. C. & Dietz, S. G. (1973), Depression in children referred to an educational diagnostic center: diagnosis and treatment. J. Pediatr., 83: 1065-1073.