Cognitive therapy strategies. During several 20-minute sessions scheduled about every 2 weeks, cognitive behavioural therapy can be introduced to teens in a psychoeducational style (Table 2).

First, introduce the concept, using a simple example of how negative beliefs are self-reinforcing. The assumption of "catastrophic" outcomes occurs in daily life on flimsy evidence. Teens can usually think of an example that has happened in the previous few days. Physicians should then explain that "your mind dwells on that worst case scenario, and your body reacts as if that awful thing has already happened, so you feel terrible, and chemical changes of depression start to happen." When you describe how this idea is well supported by animal and human models, most adolescents will find the concept quite interesting.

The implication is that they have control over some aspect of their lives, which often feel out of control. Review a typical recent example from a patient’s own experience, looking at the assumptions and errors of thinking that occurred. After this first discussion, ask teens to look for more examples before the next meeting. This "homework" extends the effect of physician contact outside office time.

Cognitive therapy does not preclude an understanding of the origins of psychological problems. One additional idea that can be readily introduced is to touch on the life experiences that "taught" the adolescent this way of thinking. Risk factors, such as abandonment, abuse, learning disabilities, medical illness, parental separation, and so on, can be integrated and linked to the current depressive way of thinking. In this sense, what appears to be a purely cognitive type of therapy in fact has an insight-oriented component. Presented in a psychoeducational way, it helps adolescents make sense out of what have been overwhelming emotional responses to overwhelming life experiences.

At the next meeting, one or two of the previous week’s examples should be examined in detail, looking at the event, the assumptions, the emotional response, and alternative explanations for the events. Adolescents are then given more "homework" of trying out a behavioural change, such as deliberately making eye contact and smiling, to see if this changes experience. Other activating behavioural steps, such as exercise or the use of structure, can also be added in as "experiments" to see if they do make a difference in the depressed mood. It is important to point out that just as negative ways of thinking and behaving have been "practised" for a long time, the new ways of thinking and behaving will need practice too.

Among the tools for cognitive therapy are logic, humour, and creativity. The result of this approach is a more assertive and less dependent adolescent. The general behavioural approach that accompanies cognitive therapy leads to more effective problem solving and taking control wherever possible. The only "side effect" of this is that others in the family or social network might resist this new assertiveness and confidence. This needs to be anticipated with a systems approach.

Cognitive-behavioural changes need to be practised, but they rapidly prove themselves effective to adolescents, who then become their own therapists. Various books written for adult patients can also help adolescents develop greater understanding and more strategies for changing depressogenic cognitive distortions. Physician-coaches can then positively reinforce these steps through infrequent booster sessions.

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