As psychiatrists, we see a fair number of non-adult patients being referred to us for various psychological problems. For general psychiatrists working in the universities and in most specialized centres, the number may be smaller because these patients are referred to child psychiatrists. For most of us including those in USM Hospital, we have to assess, analyse and manage them ourselves because we do not have specialists in the area of child psychiatry within our units.

Looking at my experience, I find the majority of cases that come to me are those in the adolescent group and the majority of them have depression as the main presenting complaint. I have used various approaches in psychotherapy with them but more recently I have attempted cognitive psychotherapy with good outcome. Most of them are very intelligent and very involved in the therapy when this aproach was used. In comparison to supportive therapy, this approach encourages them to look for answers themselves and provide the patients with the ‘power to control their lives’ which to most of them is very important.

Elsewhere, there is evedence of the effectiveness of cognitive-behavioural programs with depressed children and adolescents. For example, a study reported as early as 1986 by Reynolds and Stark, described a package of procedures drawing on social learning theory and cognitive therapy of Beck. The program was administered to a group and lasts for 21 sessions. They compared the effectiveness of the elements of this pakage, with 29 9 to 12 year olds recruited from schools who scored at least 16 on the Childrens Depression Inventory. One group of children received self-control therapy (modeled on the cognitive therapy approach with adults), the other received behavioural problem-solving therapy, which focused on fostering skills for coping with difficult situations and increasing the frequency of pleasant or rewarding events in the children’s lives. Children were treated in groups of five for 12 sessions. A third group of children were placed on a waiting list for 5 weeks, then offered the self-control therapy if they wished.

The results of this study are generally taken to show that children in both treatment groups showed significantly reduced depressive symptoms in comparison with those in the control group, and that these gains were maintained over an 8-week follow-up. This was the case to the extent that, on individual t-tests, several comparisons of mean differences (for each measure, treatment condition and pair of assessment points) were significant, and favoured the two treatments over the waiting list group.

In this article I would like to share my experiences of conducting psychotherapy with this group of patients. In cognitive psychotherapy (and in all therapies I am sure), conceptualization is of the utmost importance. In order to come to a conceptualization certain principles must be observed. In dealing with adolescents I find the following principles described by Wilkes, Belsher, Rush, Frank and associates to be very important.

1. Acknowledge the adolescent’s narcissism

“Narcissim” refers to the tendency of adolescent patients to be somewhat egocentric in the their interests and goals, often with little regard for the wishes of others and little ability to take others’ points of view. No pejorative tone is intended in using the term “narcissism”; in fact, the adolescent’s greater tendency to focus on “self” relative to many adult patients is viewed as devolepmentally appropriate. As such, both the adolescent and his parents need to understand that the therapist accepts this greater relative egocentrism and will not insist that the adolescent give this up entirely. If the adolescent’s narcissistic position is not acknowledged, the therapist risks promoting an oppositional stance, wherein the adolescent may feel obliged to defent his views strongly and thereby prematurely veto discussion on various issues.

Communication of the therapist’s understanding of an adolescent’s greater concern with himself is done indirectly, for example, by asking numerous questions about the adolescent’s view of himself, his “world” or current circumstances, and his “future” or goals, fantasies, and predictions. In other words, the therapist tries to enhance the information initially volunteered by asking question about how the patient perceives relationship among problems, people, and events, etc. Questions indicate that the therapist is interested in the detail of the adolescent’s life and “feel” the narcissism in a way that is useful both for understanding the depression and for designing appropriate interventions.

Adolescents generally want to be understood as individuals, so it is important for therapists to reflect back their understanding more frequently than might be the case with adult patients. Rather than using statements, questions are often the best way of reflecting to adolescents. For example, the question “would it be correct to say that you think...?” formally acknowledges the adolescent as the best judge of his own views. Because adolescents generally want to feel special or unique, the therapist must normally avoid use of “leveling” comments such as “ All teenagers feel that way,” or “ I’ve heard this before,” or “When I was a teenager...”  There are some exceptions to this guideline, so the therapist should be aware of these special cicumstances and use such comments only with foresight and specific purpose.

The adolescent’s sense of importance may also be acknowledged and enhanced by offering choice. As such, the cognitive therapist should make a special effort to provide the adolescent patient with a menu of choices catering to his therapeutic needs. For example, when designing homework tasks, the therapist can offer the adolescent various alternatives. Althought the therapist may have a particular technique in mind, two or three “versions” of it, differing in detail, can be presented to the patient. The important point is that adolescents will probably respond better to a choice, and the therapist will usually have to make the major responsibility for generating the menu of choices. The purpose of generating choice, as is the purpose of various other suggestions above, is to acknowldge and use the adolescent’s narcissism in the service of treating the depression.

2. Adopt a mode of collaborative empiricism

The term “collaborative” means cooperating with the adolescent, joining with him to treat the depression. The term “empiricism” means that factual data are the basic for changing cognitions or behaviors that maintain or exacerbate the depression. Although the principle of collaborative empiricism is central to cognitive therapy with any age group, observation of this principle with adolescents requires that the therapist make some adjustments relative to what might be the case in using cognitive therapy to treat adult patients.

By virtue of age, life experience, education and social norms, among other thing, adolescents will usually enter therapy with the perception that they are in a “one-down” position relative to the therapist. Therapists and adolescent patients are less “equal” in many objective ways than the therapist and adult patients. This is especially the case when the adolescent has been brought to therapy against his own wishes by concerned adults. Because of the hierarchial status difference between therapists and their adolescent patients, it is particularly important that the therapist consciously work to build and maintain a collaborative relationship. The goal of the therapist is to convey a willingness to cooperate in finding ways to ameliorate the depression.

Working in collaboration with the adolescent means that the therapist is not a “dictator” who knows best and perscribes solutions to problems. Neither is the adolescent given free rein to control the therapy by avoiding issues or focusing on tangential problems of his own choosing. The therapist must develop the skill of simultaneously “being in the room with the patient” and “adopting a metaposition” whereby the therapist guides the interaction, carefully titrating therapist and patient control of each session. Generally speaking, adolescents are acutely aware of interpersonal alliances and will react to perceived allegiances of therapists to parents or to themselves. Adopting a mode of collaboration with an adolescent does not mean that the therapist become a “coconspirator” of the patient. Implied threats or blackmail by the adolescent are not condoned, and it is important early in therapy for the adolescent to understand boundaries and limitations about suchs issues as confidentiality.

Collaboration is continuosly demonstrated throughout all interactions with adolescent patient. Setting the agenda at the beginning of a therapy session is always a join exercise of the therapist and patient. The difference between adult and adolescent patients is that the willingness and ability to participate in agenda setting will be more variable with the younger population. Some adolescents will readily demonstrate their agenda by initiating a one-sided narrative as soon as they enter the therapy room. Others will politely state something of concern when invited to do so, whereas still others initially will deny that there is anything of consequence to discuss in the session. Even when adolescent patients have been specialized into the cognitive therapy model, it is less likely that they respond well to the direct question “What should we put on our agenda for today?” Instead, the therapist should be prepared to make a quick survey of various “life sphere” or “know problem areas” in order to identify relevant agenda topics. As always, the therapist also participates in setting an agenda by stating his own topics; but with adolescents, as compared to adults, the importance of modeling is exaggerated. This means that the cognitive therapist working with adolescents should enter each therapy session mindful of the cognitive formulation regarding the adolescent’s depression so that an appropriate amount of leadership can be demonstrated in constructing an agenda that address issues central to the depression.

Not only is setting the agenda with adolescents a shared venture; throughout the session, the therapist demonstrate collaboration with respect to time spent tallking, consideration of points of view, designing homework, and scheduling future therapy session, for example. Relative to adult therapy, adolescent therapy may require the therapist to encourage cooperation (either more patient participation or more therapist participation) more often and to model cooperation more explicitly.

It is important that the message of collaboration be conveyed to the adolescent in a way that suggests that the therapist is cooperating to achieve what is best for the adolescent in the long run in the big scope of things rather than to achieve short-term egocentric demands that are not central to the adolescent’s depression. For example, although a particular adolescent may be focused on reconciliation with a boyfriend or girlfriend, the therapist may need to forget cooperating on this specific goal in favour of a more general goal such as working with the adolescent to correct a habitual cognitive distortion about the meaning of disagreements between people who purpotedly like each other (e.g., boyfriends or girlfriends).

With respect to “empiricism,” cognitive therapist working with adolescents will usually need to adopt a somewhat less “academic” approach than would be the case with adults. Adolescents will generally be less interested in discovery of maladaptive thinking patterns unless the discovery can be directed to some issues of central importance to them at the current point in time. Since the issues of greatest concern to adolescents are apt to change quickly, even from week to week, therapist may more quickly need to introduce “label” for a particular cognitive distortion that seems operative in the adolescent’s depression. Related to adolescents’ sense of urgency and their relative impatience with taking a global view of themselves and their lives, therapists should be prepared to work in the “here and now” to a greater extent than might be the case with adult patients. Some of best empirical data that can be presented to adolescents will be generated in the therapy session in the form or behaviours demonstrated by the patients themselves. Some therapists have found it very effective to read verbatim statements back to adolescent patients and inquire about the “problematic word” or the “pattern” that might be contributing to depression.

In general, adolescents will require more assistance to generalize from specific example of maladaptive thinking. It is incumbent on the therapist to remember previous examples, complete with names of relevant people and places specific to the adolescent’s life. To assist with the process of generalization, it is useful to interject brief “summaries” throughout a therapy session as well as at the end of the session so that the “take-home points” are emphasized frequently for adolescents in brief but potent doses.

With adolescents, empirical data may often be more behavioural than cognitive, especially in the beginning stages of therapy. As behavouiral data are more concrete they often have more impact, particularly with younger adolescents or those with comorbid diagnoses such as attention deficit hyperactivity disorder. Thus, for example, homework that directs an adolescent to do some novel activity rather than to think something different may more rapidly achieve the desired cognitive change. With respect to homework, specific techniques of empirical data collection must be tailored to the patient’s level of cognitive development as well as to the patient‘s immediate concerns. In general, adolescents are less inclined to do homework out-of-session than are adults, so it is particularly important to exercise ingenuity in defining homework that the adolescent is highly motivated to complete. Of course, the term “homework” is seldom used because of its possible negative association with school experiences.

Finally, the therapist must use empirical data to “adjust” the maladaptive cognitions of the adolescent rather than directly challenge them as “wrong.” If the therapist attempts to “shift” cognitive style on a continuum of adaptivity rather to “change” it, the goal usually will be met with less ressistance by the adolescent.

3. Adopt an objective stance

A therapist who has adopted an “objective stance” is one whose position is somewhat removed from the intricacies of the adolescent’s life. This does not mean that the therapist is disinterested or uncommitted but, rather able to stand back and look at the entire global picture without getting caught up in side issues or special agendas of the adolescent or his parents. Although an objective stance is crucial to cognitive therapy regardless of the patient’s age, it is sometimes hard to maintain with adolescents because they themselves are less able to suspend their narcissistic tendencies in order to consider themselves and their lives from any perspective other than the one which they currently subscribe. Because adolescents generally adhere so strongly to their views, the therapist may feel an inordinate amount of covert pressure to agree with the patient’s highly subjective point of view. Maintaining an objective stance with adolescent patients may be more difficut in some cases because the parents present a particularly one-sided view and consider themselves “unavowed experts” on their own children. Since parents are necessary participants in most adolescents’ therapy for instrumental (e.g., driving to sessions) as well as therapeutic reasons, the therapist may be tempted to give more weight to parents’ points of view than a more objective stance would support.

By definition, maintaining an objective stance requires that the therapist avoid overidentification with either the adolescent’s or the parents’ point of view. Objective need not be sacrificed by acknowledging the narcissistic nature of adolescents. Knowing in detail how the adolescent views thing does not mean that the therapist agrees that this is the only way to view them. One of the most effective ways of avoiding overidentification and of communicating the goal of objectivity to the adolescent is to involve the patient’s parents in therapy from time to time. By so doing, information is gathered from a variety of sources, and the therapist gains greater perspective. The necessity of involving family members in the adolescent’s therapy  cannot be overemphasized. This position is in contrast to that of cognitive therapy with adults, where more commonly, therapist see only the identified patients and work with their points of view regardless of what these are.

Objectivity is enchanced by avoiding adoption of “problemist” role where the therapist prescribes solutions. Rather, the therapist focuses on teaching adolescents how to develop skills for coping or resolving problems themselves. In this way, the therapist does not get entangled in the details of any particular problem but takes a more “removed” position, helping the adolescent identify and address skill deficiencies or maladaptive cognition that are common to a variety of situations.

The maintenance of an objective stance is also enchanced by the principle of collaborative empiricism. If the therapist and patient use empirical data to support or challenge particular points of view, then they probably will be less invested in unpholding any one position and more willing to be influenced by relevant factual evidence. The act of “collecting data” itself reinforces the patient’s and therapist’s view of therapy as objective.

Apart from overt demonstrations of therapist objectivity by collecting points of view from various information sources or gathering empirical data through observations and record-keeping, the therapist can covertly enhance his own objectivity by developing the skill of “parallel proccesing” or “multilevel analysis” of content and process in therapy session. While actively participating in the therapy session with such activities as asking questions, introducing topics, and directing conversation, the therapist must also listen for evidence of cognitive distortions and maladaptive beliefs inadvertently expressed in the speech of the adolescent or other family members. Whether or not identification of the distortions or beliefs is the stated goal of the ongoing interactions in the therapy session, it is crucial that the therapist listen with a “ third ear” for patterns in cognitive style that may be related to the depression. For example, an adolescent reviewing his previous week’s activities might report objective evidence of many positive occurences (e.g., passing a difficult exam, buying new clothes) but sound depressed and indicate that “nothing really good is happening in [his] life, which continues to be as bad as ever.” Further questioning about the activities may lead the observant therapist to note a disproportionate amount of time spent describing small details of things that were not “perfect” in the adolescent’s eyes, and lead the therapist to form (silently) the hypothesis that the adolescent upholds the same perfectionistic standards that have been noted in the patient’s high-achieving parents. Furthermore, the therapist might suspect that the adolescent habitually disqualifies the positive, magnifies the negative, and tends to personalize serendipitous events, hereby maintaining a depressogenic view of his life and himself. The practice of listening with a third ear helps the therapist maintain an objective stance (avoiding premature commiseration with the adolescent) by raising the possibility, at least in the therapist’s mind, that there is another way of interpreting the same events. Many adolescents are experts at giving passionate presentations of depressing points of view, which, if adopted by the therapist, would make amelioration of the depression extremely difficult. The therapist accepts the narrative as the true current perpective of the depressed adolescent but does not agree that another perpective is not possible. It should be noted that, in some cases, the adolescent’s complaints are entirely accurate as stated, in which case the therapist collaborates to solve a problem or instruct the patient in coping or skill acquisition, rather than identifying and changing cognitive distortions. In any case, the therapist’s goal of objectivity is enhanced by actively, consciously, and constantly using information provided by the patient to formulate and test hypotheses about the cognitions that may be related to the adolescent’s depression.

There are seven other principles and they will be dealt with in the next issue. Watch out this PERSIKOL home page for help on dealing with adolescents.