Based on our review of available research on the treatment of adolescent depression (summarized in Curry, Wells, & March, 2005
), we chose a cognitive-behavioral treatment (CBT) approach for TADS. The primary goal of cognitive therapy is to help the depressed individual become aware of pessimistic and negative thoughts, depressotypic beliefs, and causal attributions in which the person blames him/herself for failures but does not take credit for successes. Once these depressotypic patterns are recognized, the client is taught how to substitute more realistic constructive cognitions for these counter-productive ones. The primary goal of behavior therapy for depression is to increase engagement in behaviors that either elicit positive reinforcement or avoid negative reinforcement from the environment. The TADS CBT intervention for adolescent depression (Curry et al., 2000) combines cognitive and behavioral strategies aimed at ameliorating the types of problems that commonly characterize depressed adolescents (e.g., pessimism; internal, global, and stable attributions for failure; low self-esteem; low engagement in pleasant activities; social withdrawal; anxiety and tension; low social support and increased interpersonal conflict). The treatment incorporates other elements common to cognitive-behavioral treatments, such as the focus on specific and current actions and cognitions as targets for change, structured intervention sessions, repeated practice of skills, use of rewards and contracts, and a relatively small number of therapy sessions. To encourage greater generalization of the therapy skills to everyday situations, adolescents are given homework assignments to be completed outside of the session, which are reviewed at the beginning of the subsequent session.
Stages of CBT in TADS
In TADS, CBT occurs in three stages: Acute treatment, Continuation, and Maintenance. Acute treatment consists of 12 weekly sessions and is focused on alliance building, goal setting, and skill building. In the early sessions of Acute treatment, basic behavioral and cognitive skills (e.g., mood monitoring and pleasant activities) are introduced. In the later sessions of Acute treatment, more complex and individually tailored skills (e.g., social skills, negotiation and compromise) are the focus of treatment. During Acute treatment, there are two parent-only sessions devoted to psychoeducation and at least one conjoint family session. The Continuation stage of CBT is six weeks in duration, with weekly sessions for partial responders and biweekly sessions for full responders. For adolescents who fully respond to treatment, these sessions are aimed at consolidation of gains and relapse prevention, with no new skills introduced. For teens who only partially responded during the first 12 weeks, new skills from the TADS manual can be introduced as needed to further enhance treatment gains. The last session in the Continuation stage is devoted to developing a relapse prevention plan. The Maintenance stage of CBT is 18 weeks long with visits scheduled every six weeks. In this phase, sessions are oriented around skill consolidation, maintenance of gains, and relapse prevention. Homework is regularly assigned across all three stages of treatment. In this paper, we will focus on the Acute treatment stage; Continuation and Maintenance phases of treatment will be addressed in Simons et al. (2005)
in this volume.
When delivering a manual based intervention, it is important to balance therapist flexibility and adherence to the manual. TADS CBT utilizes a modular approach to assure such a balance. This approach is intended to maintain a clear CBT rationale and treatment model, to utilize structured, empirically supported treatment components, and to permit individual applications that meet the needs of a wide variety of teens and their parents. Thus, CBT in the Acute stage consists of teaching a set of skills modules (all to be discussed below) some of which are required, others of which are optional. One of the major ways in which treatment is individually tailored within TADS is the use of collaborative (i.e., the teen and the therapist together) agenda setting at the beginning of each session. In addition, while certain skills are required, additional skill modules are available depending on the needs of the specific adolescent. TADS CBT also incorporates the flexibility to addressed crises that arise (e.g., school refusal, suicidality) within regularly scheduled sessions or by using additional crisis sessions (i.e., Adjunctive Services and Attrition Prevention; ASAP), a certain number of which are allotted to each stage of treatment.
General Structure of TADS CBT Sessions
TADS CBT sessions are moderately structured, with the goal of balancing skill training and supportive, empathic listening (Carroll, 1998
). Although the focus of each session varies depending on the specific skills being addressed and the needs of the individual client, TADS CBT sessions have a fairly consistent format, which is described to the adolescent in the first individual session. The hourly session is divided into three sections, each lasting approximately 20 minutes.
In the first third of the hour, the therapist checks in with the adolescent regarding depression symptoms since the last session, reviews the homework assignment from the previous session, and sets the agenda in collaboration with the client. If the homework has not been done, the therapist brainstorms solutions with the client to increase the likelihood of future success, and attempts to complete the homework in the session. When homework has been completed, the adolescent should be strongly reinforced and encouraged to make an internal attribution for that accomplishment.
The middle third of the session is typically devoted to learning a new CBT skill or continuing to work on a skill that was introduced in an earlier session. CBT skills are most relevant to a client when they are linked to the adolescent’s personal concerns and life experiences. Skills can be taught using a variety of techniques, including didactic teaching, modeling, role-playing, and Socratic questioning. Adolescents are encouraged to learn a variety of skills, with the expectation that not all skills will be useful to them, but that we do not know a priori which skills will be most powerful in improving their mood.
The final third of the session is devoted to addressing additional issues raised by the adolescent and planning a homework assignment for the upcoming week. Often, non-CBT therapists (and many beginning CBT therapists) do not devote enough time to planning the homework assignment. To maximize the therapeutic effectiveness of homework assignments, the therapist needs to make sure of several things: that the adolescent understands and accepts the rationale for homework, knows how to complete the assigned homework, has a plan for how they will remember to do the assignment outside of session, anticipates problems to completing the assignment, and brainstorms solutions to address these potential problems. Homework assignments need to be developed in consideration of the unique needs and abilities of the adolescent.
Parental Involvement in TADS CBT Sessions
Parents are typically the ones who have sought treatment for their teen, and they are often instrumental in ensuring treatment attendance. In addition, several factors involving the parents (e.g., marital discord, high parental expectations, poor problem solving skills, low rates of pleasant activities involving the family) often contribute to maintaining the adolescent’s depression. For these reasons, parents are viewed as important members of the treatment team that is joined together against a common enemy – the adolescent’s depression. Parents participate in treatment both by attending individual psychoeducation sessions and conjoint teen-parent sessions. In the Acute phase of treatment, there are two parent psychoeducation sessions and at least one conjoint session. In the psychoeducation sessions, the therapist reviews the skill-based modules with the parents, apprises them of the treatment and progress toward goals, and helps them understand ways in which they can reinforce the skills at home. In conjoint family sessions, family members can work together to identify and improve problem areas. In addition, during individual sessions with the adolescents, the TADS CBT therapist may “check in” with the parents for up to 10 – 15 minutes at the start of the session. The purpose and components of the parent sessions are described in more detail in Wells and Albano (2005)
The Therapeutic Relationship
As is true of any psychotherapeutic intervention, TADS CBT needs to be conducted within the context of a strong working alliance and therapeutic relationship between the adolescent, parents, and the therapist. Essential therapist characteristics include the capacity for accurate empathy, warmth, genuineness, and an ability to establish rapport with a diverse range of adolescents and parents. At times the therapist who works with the adolescent must maintain an alliance both with the teenager and the parents in the face of conflict between the adolescent and the parents.
The essential characteristics of the therapeutic relationship with the adolescent and parent include rapport and collaborative empiricism. Rapport refers to the therapist’s ability to establish a connection with clients so that they feel accepted and able to express thoughts and feelings without fear of reproach. Collaborative empiricism refers to the therapist’s ability to “work with” with the teen in looking for evidence regarding the accuracy of thoughts, establishing the session agenda, and choosing and planning homework. For example, one of the challenges is to question the client in a way that feels supportive and nonjudgmental. Therefore, the therapist who discovers that the adolescent is not completing the homework assignments may use the collaborative spirit so that therapist and teen think together as scientists about the obstacles that may be interfering with homework completion and then generate solutions to ensure more success in future homework completion.