CBT sessions are moderately structured, with the goal of balancing skill training and supportive, empathic listening. Although the focus of each session varies depending on the specific skills being addressed and the needs of the individual client, CBT sessions have a fairly consistent format, which is described to the adolescent in the first session.

Most sessions begin by creating a session agenda, checking in with the adolescent regarding depression symptoms since the last session, and reviewing homework assignments from the previous session. Creating an agenda collaboratively helps the adolescent know what topics will be covered in the session—there are no secrets. Knowing what to expect helps diminish the client’s anxiety and helps him or her stay on track. Mood monitoring—one of the core CBT skills discussed later in this chapter—provides an efficient method of quickly monitoring whether any particularly difficult experiences occurred since the last session. Helping clients establish the habit of doing their homework between sessions is based on the assumption that applying CBT skills to the adolescent’s day-to-day life is where real change occurs. 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 as much of the homework in the session as possible. When homework has been completed, the adolescent should be strongly reinforced and encouraged to make an internal attribution for that accomplishment.

The middle portion of most CBT sessions is devoted to learning a new skill or refining 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 brief lectures, modeling, role-playing, and Socratic questioning. Adolescents are encouraged to learn a variety of skills, with the expectation that not all skills may be useful to them but that we do not know a priori which skills will have the most powerful influence in improving their mood.

The final portion of each session is devoted to addressing any 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 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 he or she will remember to do the assignment outside of session, anticipates problems to completing the assignment, and brainstorms solutions to address these potential problems. The therapist should be clear and specific when developing the homework assignment and questions should be encouraged to anticipate potential problems. Prior to ending each session, the therapist can tell the client the general focus of the next session. Letting clients know in advance what to expect keeps things out in the open, making them “informed consumers.” This is a respectful way to keep the adolescent engaged in therapy and hopefully increases the probability of continued attendance.

As is true of any psychotherapeutic intervention, CBT with depressed adolescents needs to be conducted in the context of a strong working alliance and therapeutic relationship among 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 two.

Parents and other guardians are an integral part of the adolescent’s social system. They 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. In TADS CBT, parents participate in treatment both by attending individual psychoeducation sessions and conjoint teen-parent sessions. In these 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 their child using these skills at home. In conjoint teen-parent sessions, family members 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 to 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).

Like other depression interventions, CBT occurs in three stages: acute, continuation, and maintenance treatment. Acute treatment, which aims to achieve a full recovery from the depressive episode, consists of a relatively brief number of weekly sessions, typically 12 to 18, and is focused on forming a therapeutic alliance, developing goals, and learning skills to combat depression. In the early sessions of acute treatment, basic behavioral and cognitive skills (e.g., mood monitoring, pleasant activities) are introduced, followed by more complex and individually tailored skills in latter sessions (e.g., social skills, negotiation, and compromise). Continuation treatment occurs after the adolescent has achieved a strong response to care. These sessions begin to occur less frequently (biweekly or monthly) and are aimed at consolidating gains and preventing relapse, with no introduction of new skills. The last session or sessions in the continuation stage is devoted to developing a thorough relapse-prevention plan. Maintenance treatment, which aims to maintain gains and prevent recurrence, can last a few months to a few years, depending on the previous depression history, and generally consists of less frequent sessions (e.g., every 6 to 8 weeks). Homework is regularly assigned across all three stages of treatment.

By definition, cognitive-behavioral therapy requires the use of concepts and techniques to change both cognitions and behavior (actions). In the treatment of depression, the behavioral component focuses on increasing the frequency of pleasant (“fun”) activities, and the cognitive component focuses on identifying and challenging frequent negative thoughts. In treatments that adopt a predominantly cognitive approach, core schema can be identified and changed but these types of treatments require a fairly long duration and have not been evaluated extensively in clinical trials with depressed adolescents. Prior to the behavioral and cognitive work that forms the basis of CBT, a model of change is taught, along with mood monitoring to track progress. These four skills (i.e., Treatment Rationale, Mood Monitoring, Behavioral Activation, Cognitive Restructuring) are components of all CBT approaches with depressed adolescents. Later we review each of these skills by describing the rationale for their inclusion in the treatment of depression, the format that is generally used to teach the skill, and common challenges that can arise for each skill area. Transcriptions from CWD-A course sessions are provided to illustrate the delivery of core CBT skills. After describing the core CBT skills for depression, additional optional skills are described that can be incorporated into treatment, depending on the specific needs of the depressed adolescent.

In this section, we review the relevancy and importance of treatment rationale and goal setting in CBT.

Why It’s Relevant

The first CBT session is generally conducted with both the adolescent and his or her parent(s). Based on the CBT premise that treatment should start with a model of change that is shared with the client, the therapist educates the family about the cognitive-behavioral model of depression and the treatment that is derived from this model. It’s important to have a model or rationale for treatment and to share that rationale with the client. The treatment model provides a “map” for treatment, and just like a road map, is only a representation of the real terrain; the model may not contain all the factors that led to the adolescent’s depression. The treatment model does, however, serve as a guide to get the person from where they are to where they want to be. Most people who enter the course feel that they have little or no control over their moods and giving them a model gives them a sense of control and hope.

Additional aims for the first CBT session are to elicit a list of the initial treatment goals from the adolescent and parents, link those goals to the CBT model, and begin establishing a collaborative therapeutic alliance with both the adolescent and parents.

How It’s Implemented

After a brief introduction, the CBT therapist obtains a description from the adolescent and parents of the presenting problems. This information is helpful in personalizing the subsequent presentation of the CBT model of depression and treatment. Knowing the pressing concerns of the family and linking those concerns to the treatment model are important in fostering hopefulness that treatment will be of benefit to the specific problems the client is experiencing.

The CBT model of depression is based on the following assumptions. First, depression is more than “feeling bad.” It is a disorder that changes a person’s mood, thinking, behavior, and biology. Second, depression has many possible origins; there is no single cause that applies to everyone. Third, effective treatments for depression are available, and CBT has received some of the strongest research support.

In this section, we review the relevancy and importance of mood monitoring in CBT. Additionally, we provide a clinical example of mood monitoring in group CBT.

Why It’s Relevant

Mood monitoring is a basic skill that is taught to depressed adolescents as a way of tracking how they feel. It is generally taught in the first session and is one of few skills discussed in each session throughout treatment. Mood monitoring serves several functions. First, it provides important baseline information regarding how the adolescent is feeling at the beginning of treatment. Second, mood monitoring gives the therapist and the adolescent a common language when discussing emotions. For example, in the CWD-A course (which uses a 1- to 7-point mood monitoring scale), when the adolescent reports that her mood was a “1” (i.e., the saddest she ever felt), that means something very different from when her mood was a “3” (below average but much closer to neutral). Third, it helps to challenge the cognitive distortion that “I’m always depressed” by showing clients that, while their moods may not fluctuate from terrible to fantastic, they almost always vary from bad to at least “less bad” or even “average.” Fourth, mood monitoring helps the adolescent learn which specific situations or times of the day or week are associated with feeling more or less sadness or irritability. Then, instead of having a vague sense of what contributes to feeling better or worse, teens will understand their depression better and feel more empowered to do something about it. Once situations have been identified that are associated with feeling better, the goal will be to increase such activities. Thus, mood monitoring leads naturally into the Pleasant Activities module. Fifth, mood monitoring can help the client identify which skills in the course have the most powerful effect on improving his or her mood.

How It’s Implemented

Mood monitoring requires that upper and lower mood anchors be defined and that a mood monitoring form be used daily. In TADS CBT, mood anchors are created using the 11-point Emotions Thermometer. The session begins by teaching teenagers that emotions vary in strength, and that by using an Emotions Thermometer, they can understand not only what they are feeling, but also how strong that emotion is. Adolescents are taught to rate emotions, ranging from 0 (very bad) to 10 (very good). To provide concrete anchor points for the thermometer, the therapist asks the teen to recall two or three experiences in which he or she felt bad, and two or three in which he or she felt good, and to rate these experiences, generating experiences that vary in intensity so that the whole thermometer range can be used. This exercise provides an opportunity to highlight to the adolescent that feelings range from good to better, and bad to worse, and concomitantly, that even though it might seem like they feel bad all the time, by using the Emotions Thermometer they can see how their emotions change over time.

Next, the mood monitoring form is introduced as a way to track each day the situations, events, and thoughts connected with feeling good or bad. Using several examples, teens are taught to rate their moods using the Emotions Thermometer. It is helpful to use examples that the teenager has brought up in the session to illustrate how to use the mood monitor. For homework, the client is instructed to notice and record situations that happen in the morning, afternoon, and evening each day of the week that are associated with feeling good or feeling bad.

Common Challenges and Possible Solutions

Mood monitoring can present several challenges to the CBT therapist. As in the example, some clients have trouble creating an upper anchor (“I’ve never had a 7 day. My life has always been bad”). Emphasize that each person’s life has been different and that each person’s highs and lows therefore are different. Encourage the adolescents to carefully review their entire lives and look for a time (even if it was fairly brief) when they were their very happiest. It could have been a trip or a time when something really nice happened to them, a special party or celebration, a time when they had a good friend or pet that they loved very much. That becomes their 7. If you still receive resistance, ask them to choose a time when they were the least depressed.

Many depressed adolescents experience a range of emotions throughout the day. Encourage them to try to average their moods for the day. If this is difficult, ask them to describe a recent day that had a wide variety of changes and help them come up with an average (or, if applicable, ask the group to suggest how they would rate the day). It’s important to not let one negative event overshadow how they felt for the majority of that day.

Other common obstacles with mood monitoring are that the client forgets to complete the form or finds it overwhelming. In either of these cases, attempt to reconstruct the information and fill out the tracking form as completely as possible in the session and help the adolescent decide on one time in the evening to look back over their day and record their mood, as well as a particular place where the form will be kept (e.g., on a bedside table, in her or his backpack with other “homework”). They may need to put a reminder somewhere in the house or ask their parent to remind them.

Lastly, mood anchors are generally created in the first session and the therapist needs to be prepared for the adolescent to reveal childhood traumas or other severe negative events when creating the lower mood anchor. Acknowledge the intensity of emotions while remaining calm. If you are conducting group CBT, you might offer to talk more with the adolescent in private after group. Be sure to check in with the adolescent before the session is completed to assess his or her current emotional state. Additional treatment, specifically focused on the trauma, may be necessary. Consult with a supervisor or colleagues regarding ethical/reporting obligations.

In this section, we review the relevancy and importance of behavioral activation in CBT.

Why It’s Relevant

Sessions designed to increase pleasant activities are based on the assumption that relatively low rates of positive reinforcement are critical antecedents of depressive episodes (Lewinsohn, Biglan, & Zeiss, 1976). Research has shown that the association between our moods and our positive activities level is surprisingly strong. This is a simple but powerful tool in feeling better. Like depressed adults, depressed adolescents often stop engaging in activities that once were enjoyable. Their repertoire of fun activities frequently is reduced to a small number of solitary, relatively passive activities (e.g., computer videogames, watching television, listening to potentially depressing music).

To increase their fun activity level, depressed adolescents are taught basic self-change skills, including (a) identifying activities that are enjoyable for them, (b) keeping track, or “baselining,” their current pleasant activity level, (c) looking at the connections between their activity level and mood, (d) setting a realistic goal for increased pleasant activities, (e) developing a contract to do more fun activities, and (f) reinforcing themselves for achieving the goals of their contract.

How It’s Implemented

The therapist begins by explaining the rationale for this skill, which is to increase the level of pleasant activities. Three categories of fun activities—social, success, and physical—appear to have the most powerful influence on our moods. For most individuals, doing things with other people has a more positive impact on their moods than doing things alone. “Success” activities refer to doing things that we are particularly competent at or completing a difficult task. Last, a growing body of research is documenting the powerful effect exercise has on an individual’s mood. Our goal is to have adolescents do at least a few activities in each of these three categories.

Once the rationale is established, generate a personalized list of pleasant activities, having the adolescent think of as many fun activities as possible. Be specific and include easy-to-accomplish activities, such as making a phone call or doing little things around the house. Given that you will usually have had a few sessions with the adolescent, you can provide a reminder of previously mentioned enjoyable activities if he or she is unable to remember them. Continue until the adolescent has generated a list of at least 10 activities.

Next, review the list to select specific activities to track and increase. Potential mood-enhancing activities should meet the following criteria: (a) personally enjoyable to the adolescent, (b) active rather than passive, (c) inexpensive, (d) not harmful to oneself or others, (e) can be done at least weekly, and (f) do not require the cooperation of many other people. If the adolescent is experiencing significant psychomotor retardation or is unable to identify pleasant activities, the therapist may need to begin with activity scheduling (Brent & Poling, 1997). If activity scheduling is indicated, a weekly schedule is created in which the adolescent identifies activities to do at specific times each day, including simple, routine activities, such as eating breakfast, taking a shower, and so on. The teen does the activities and then rates each activity on two dimensions: mastery (sense of accomplishment) and pleasure (enjoyment level), using the 0- to 10-point scale similar to the Emotions Thermometer. Once pleasurable activities are identified in subsequent sessions, they can become the focus for behavioral activation.

Once the list of approximately 10 to 20 activities has been generated, the therapist needs to determine a baseline rate of activity. This can be done either by assessing the rate of activity engagement for the previous three or four days or having the client track her or his activity level (and mood) for 1 or 2 weeks, without specifically aiming to increase that activity level.