This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adolescents and families, and access to supervision. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reformulated in our own words and never reproduced: consult the original manuals for the letter of the text.
1. The programme at a glance
Indication. Anxiety disorders in adolescents aged 12 to 18: social anxiety — the dominant form at this age — generalised anxiety, panic disorder, specific phobias, persistent separation anxiety, and the mixed presentations that are the rule.
Reference model. Cognitive behavioural therapy, whose efficacy is established in adolescents as in children. The reference is the multimodal trial of Walkup and colleagues (2008), which included adolescents. For social anxiety, which dominates at this age, individual cognitive therapy based on the Clark and Wells model adapted to adolescents (Leigh & Clark, 2018) gives the most precise guidance. For panic disorder, the protocol of Pincus and colleagues has been evaluated specifically.
Format. Fourteen individual sessions of 50 minutes with the adolescent, and four sessions with the parents. About four months, plus two booster sessions. Fewer parent sessions than in the manual on children, and that is deliberate: at this age the work is primarily individual, and autonomy is part of the treatment.
A warning about honesty. The data suggest that the response is sometimes slightly weaker in adolescence than in childhood. The analyses are mixed and the probable explanations are known: more comorbidity, more severity, longer-standing presentations, frequent associated depression. That does not change the indication; it does require treating the comorbidities, not skimping on the exposure, and not promising a quick result.
Target mechanism. Not the disappearance of anxiety, but four changes: facing what is avoided, giving up safety behaviours, coming out of self-focused attention, and no longer living according to what other people might think.
| Session |
Focus |
What the session produces |
| 1 |
Welcome, alliance, confidentiality, assessment |
What they say about it, in their own words |
| 2 |
The picture, the risk, the formulation |
Diagram written with them |
| 3 |
The model, the goals, the ladder |
Three goals, hierarchy opened |
| 4 |
The tools, and their rule of use |
Three tools tried |
| 5 |
What I think they think |
Two predictions written |
| 6 |
The first exercise, in session |
Exposure done, prediction reviewed |
| 7 |
Safety behaviours |
Inventory, one dropped |
| 8 |
Being seen, speaking: the social |
Two social exercises, measures |
| 9 |
Sensations and panic |
Exposure to sensations |
| 10 |
Performance and perfectionism |
One standard deliberately lowered |
| 11 |
What goes round: worry and rumination |
Period installed |
| 12 |
School and exams |
Written plan |
| 13 |
Sleep, screens, what is left |
Final inventory |
| 14 |
Stocktake, plan, what comes next |
Summary sheet written by them |
| Parent session |
Placement |
Focus |
| P1 |
Before session 1 |
Assessment, information, frame, confidentiality |
| P2 |
After session 3 |
Accommodation, reassurance, what is asked of them |
| P3 |
After session 8 |
School, expectations, their own anxiety |
| P4 |
After session 13 |
Stocktake, plan, autonomy |
What the adolescent takes away. Seven printable worksheets, listed in section 37 and downloadable from this page: what it costs me, my ladder, my exercises, what I think they think, my safety behaviours, what goes round, my plan.
What sets this programme apart from a space to talk. The active component is exposure, and at this age it takes a particular form: these are not endurance exposures, they are experiments that test a precise prediction about what other people will do and think. An adolescent who talks very well about their anxiety for fourteen sessions and has never asked a question in class has not been treated.
2. Before you start
Who this programme is for
This text is addressed to psychologists, child and adolescent psychiatrists, psychotherapists and mental health nurses trained in cognitive behavioural therapy with adolescents. It assumes that you can see an adolescent alone, assess suicide risk, spot self-harm, and work with parents who no longer have any purchase.
It is not written for families. It contains criteria for non-response, what must not be said, and a diagnostic discussion that parents would read as a judgement.
The prior question
Three decisions are taken in sessions 1 and 2.
Is there a risk? Suicidal thoughts, self-harm, dietary restriction, bullying, substances. That comes before everything, and section 10 says how to look for it.
Is there something else in the foreground? A depression, an undiagnosed attention disorder, an eating disorder, an autism spectrum condition, ongoing bullying. See section 9.
Is there a disorder? Adolescence is an age of normal social anxiety: feeling watched, dreading other people's eyes, being uncomfortable in a group — all of that is part of development. What makes a disorder is the impact — school, friends, activities, sleep.
What this programme is not
It is not a treatment for adolescent depression, which has its own protocol. It is frequently associated, and the order of treatment is a matter for discussion: see section 11.
It is not a treatment for obsessive-compulsive disorder or post-traumatic stress, which each have their own protocol.
It is not a treatment for eating behaviour.
It is not a treatment for school refusal established over months, which requires a broader arrangement: see section 33.
It is not a programme for children under twelve. Below that, the parental work is central and the frame of this manual does not suit — there is a separate manual for that age group.
The frame, to be laid down before the first session
Consent. Treating a minor requires the agreement of those with parental responsibility. The adolescent's own buy-in is something else, and it is what decides the result.
One useful difference from the behavioural presentations: anxious adolescents often come of their own accord, because they are suffering and want it to stop. That is a considerable asset, and it should not be wasted by treating them like adolescents brought under duress.
Confidentiality. Stated in front of the adolescent and in front of the parents, in the same terms, at the first meeting: "what you tell me stays between us. I will tell your parents what we are doing, not what you say. There are two exceptions: if you are in danger, or if someone is hurting you — and in that case I will tell you before I talk about it."
Hold to it. At this age, what matters is often precisely what the parents do not know.
How to use it
Read the whole thing before session P1, and in particular sections 10 and 32: risk screening and the conduct of exposure.
Every session is described on the same frame: the objective, a step-by-step run-through, what to say, the common mistakes, and the criterion for moving on.
One warning specific to this age. The anxious adolescent is an excellent patient on the face of it: they talk well, they are intelligent, they understand everything, they hand in their worksheets. And the session can pass very agreeably analysing their thoughts for four months without their ever having faced anything. That is the central drift of this treatment, and it is comfortable for both parties.
3. What is normal in adolescence
This section serves your diagnosis and what you will say to the parents.
What is normal, and widespread
Self-consciousness. The adolescent feels watched, evaluated, compared. That is a normal transformation of this age, and it is sometimes painful without being pathological.
Sensitivity to peer judgement. It peaks in adolescence, and it has a function: that is how one learns to live in a group.
Worry about appearance.
Nerves before a presentation, an exam, a competition. Universal, and useful.
The need to move away from parents, and the refusal to tell them things. That is a task of this age, not a symptom.
The sleep shift. The internal clock genuinely moves later in adolescence, and the need stays at eight to ten hours. An adolescent who does not fall asleep before midnight is not necessarily anxious.
What should cause concern
The impact, and it alone:
school — absences, dropping out, refusing to go, no participation, exams missed;
friends — invitations turned down, isolation, activities abandoned;
activities stopped: sport, music, clubs, a summer job;
sleep collapsed or the rhythm reversed;
meals avoided in public, or dietary restriction;
daily physical complaints;
panic attacks, with avoidance of places;
use of alcohol or cannabis that visibly serves to get through social situations;
self-harm;
thoughts of death.
The difference between shyness and disorder
Many of these adolescents have a reserved temperament, identifiable since childhood. It is not an illness and it is not cured.
What is treated is what that temperament becomes when avoidance sets in: a reserved adolescent who has stopped trying, and who organises their life so as not to be seen. Say it in these terms: "you will probably stay someone who is quiet, and there is no reason to change that. What we are going to change is that you can do what you want to do."
4. The clinical picture
What the adolescent describes
Better than a child, and often with great precision. They describe what they dread, what they do to avoid it, and what it costs them. They often already have a theory of their own functioning, sometimes read somewhere.
What they describe less well, and what has to be looked for: the safety behaviours, which they do not realise keep the problem going; the self-focused attention in situations; and what they have gradually stopped without deciding to.
The sentences that recur: "I know it is irrational", "everyone is looking at me", "I am going to make a fool of myself", "afterwards I go over it for hours", and "I would rather not go than fail".
What the parents describe
An adolescent who refuses everything, who stays in their room, who does not want to go to school any more, who has stopped sport. Often a conflict about going out and about obligations. And frequently a worry they express badly: they no longer know what to require, and they oscillate between pushing and protecting.
What keeps the anxiety going
Avoidance, and at this age it is often invisible: not signing up, not replying, not putting themselves forward, choosing the least exposed course, not applying, not speaking up. It is not a spectacular refusal, it is a series of silent renunciations.
Safety behaviours. The most important factor in social anxiety, and the most neglected. Speaking quietly, not looking, hiding behind their hair, keeping their hands in their pockets, preparing every sentence, only talking about safe subjects, arriving late to avoid the waiting, staying near a friend, keeping their phone in their hand. Each reduces the anxiety at the time, prevents them from discovering that the situation goes well, and sometimes attracts the very attention it is meant to avoid.
Self-focused attention. In a situation, the adolescent monitors themselves instead of looking at what is going on. They see themselves from the outside, as an image, and they take that image for reality. It is a central mechanism of social anxiety, and it is directly treatable.
Anticipation and rumination. Hours beforehand, rehearsing the scene; hours afterwards, replaying it looking for the mistakes. Those two stretches consume more life than the situation itself.
Reassurance and checking. From parents, from friends, and increasingly by message.
Screens as a safety behaviour. A point specific to this age: the phone allows them to be present without being exposed, to communicate without speaking, never to be alone facing a group. It is a powerful and socially invisible avoidance.
Parental accommodation, more discreet than in childhood but real: phoning for them, writing their emails, making excuses for them, doing the errands, getting them excused.
Epidemiology, in two useful figures
Anxiety disorders are the most frequent mental disorders of adolescence, with estimates of the order of 6 to 10 % depending on definitions.
Social anxiety is the form that most often declares itself at this age, with a peak of incidence between twelve and sixteen — which makes it the most frequent reason for this programme.
5. The forms, and what they change
Social anxiety
The dominant form in adolescence, and the one that structures this manual.
The situations: speaking in class, being asked a question, giving a presentation, joining a group, eating in front of others, being photographed, telephoning, addressing an adult, going to the changing rooms, using the school lavatories, posting something, being seen failing at something.
The particular targets: safety behaviours, self-focused attention, the image of the self seen from outside, anticipation and rumination. The Clark and Wells model, adapted to adolescents, indicates precisely these targets, and it allows more effective work than simple graded exposure.
Three tools are particularly profitable at this age: manipulation experiments with safety behaviours, video feedback, and peer surveys.
Generalised anxiety
The adolescent worries about everything and always has: marks, the future, choices, health, their parents, the climate, war, money. Often described as mature and conscientious. They ask for reassurance, redo their homework, want to be sure before deciding.
The targets: intolerance of uncertainty, certainty seeking, perfectionism, and a worry period — session 11.
Panic disorder
Appears in adolescence, often after puberty, and it is frequently missed: the attacks are taken for faints, heart problems, low blood sugar, and the adolescent ends up in A&E.
The targets are those of the adult protocol adapted: the interpretation of sensations, exposure to the sensations themselves, stopping safety behaviours, and taking back the places avoided. A protocol specific to adolescents has been evaluated (Pincus et al., 2010).
Specific phobias
Often long-standing and sometimes very disabling: injections — which compromise medical care — vomiting, transport, flying, heights, animals. An isolated phobia with no other disorder is treated very quickly: see section 33.
Persistent separation anxiety
Less frequent at this age and heavier when it persists: the adolescent does not sleep away from home, does not go on school trips, cannot be left alone, phones several times a day. It blocks steps towards autonomy that matter, and it deserves to be treated in its own right.
Performance anxiety
Not a diagnosis, but a frequent reason for coming: exams, competitions, entrance tests, auditions. Often in adolescents who succeed, with a perfectionism and a fear of failure that cost a great deal. Session 10 is devoted to it.
Frequently asked questions
How do I tell normal adolescent social anxiety from a disorder?
By the impact, not by the intensity of the discomfort. Feeling watched, dreading other people's eyes, being uncomfortable in a group: that is this age. What makes a disorder is what is lost — participation in class, friends, activities, applications, sleep. A reserved adolescent who has friends, goes to school and plays sport does not need to be treated, and saying so often relieves worried parents.
They talk very well about their anxiety and understand everything. Is that a good sign?
It is an asset and a trap. Those are the adolescents with whom you can spend four months analysing thoughts in an excellent atmosphere without their having faced anything. Set yourself the accounting criterion at session 8: how many exercises actually done? And tell them frankly in session 3 that understanding their anxiety does not change it — they know, and they appreciate being told.
They do the exercises but nothing changes.
Look first for the safety behaviours: they are exposing themselves with all their protections, and therefore learning nothing. Do the manipulation experiment from session 7 — the same situation with and without, compared — and you will often see the blockage give way in one session. Then check whether their predictions were checkable: "it will go badly" cannot be disconfirmed. And check that they do not systematically conclude "I was lucky".
Video feedback — is it really necessary?
It is one of the most effective interventions in social anxiety, and avoiding it is often the therapist's avoidance rather than the adolescent's. One condition makes it useful and its absence makes it useless: having them write down before filming, precisely, how much they think it will show that they are red, that they are shaking, that they are uncomfortable. It is the gap between that prediction and the image that produces the effect. Without it, they will watch the video with their inner eye and see only what they feared.
What do I do when they drink before parties?
Treat it as a safety behaviour, not as a moral failing — and put it that way: "this is not a reproach, the problem is that it stops you discovering that you can do it without." Then make it an item in the hierarchy, with a written prediction. The same goes for an anxiolytic taken before a situation: it is a protection, and it must be removed with the prescriber's agreement.
The parents want them to "make an effort" and go out.
They are half right, and the missing half is the method. Explain the difference between pushing and grading, and give them the formula that contains both: "I know it is difficult, and I know you can do it." Then get to the real issue in session P3: two or three non-negotiable obligations, and the rest left to their decision. The most frequent lapse is not excessive expectation: it is the opposite, parents who no longer expect anything for fear of pushing them over the edge.
Should an adolescent be made to give a presentation?
Never force — at this age, that ends the treatment. Grade it: the presentation in front of you, then in front of three classmates, then in front of half the class, then in front of everyone. And get a teacher's cooperation, which is the most useful and least made request. What should be refused, on the other hand, is being excused oral work: it installs avoidance for all the years to come and it is very difficult to undo.
They have panic attacks and have been to A&E.
Treat the panic in its own right, with session 9: the interpretations of the sensations, then exposure to the sensations themselves — hyperventilating, spinning on a chair, breathing through a straw — until they become boring. Remove the safety behaviours: the water bottle, the tablet in the pocket, the seat near the exit, checking the pulse. And always look for agoraphobia: it sets in fast and it restricts life more than the attacks.
They have refused to go to school for three weeks.
The return becomes the main objective, and it must be quick and partial: one hour a day straight away is better than the full timetable in two months. A written plan with dated stages, negotiated with the school. And settle the physical-complaints protocol before the first day — otherwise the first trip home cancels everything. Look for what made school impossible: an oral, a subject, bullying, a humiliation.
How do I know whether it is social anxiety or autism?
The question that orients: are the social difficulties a fear of judgement, or a difficulty in understanding the codes and sustaining interaction? An adolescent who knows perfectly well how to enter a conversation but does not dare belongs to the first case; an adolescent who does not know how belongs to the second, and that is not treated by exposure but by explicit teaching. The two often coexist, and autism is diagnosed late in girls.
Is medication needed?
Begin with therapy in mild to moderate anxiety. Discuss a child psychiatry opinion if the anxiety is too severe for them to engage in the work, if there is no response after eight to ten well conducted sessions, where there is an associated moderate to severe depression, in prolonged absence from school, or in the face of a very disabling panic disorder. The reference trial showed that the combination does better than either treatment alone: so it is never an admission of failure.
They are better, but they are choosing a course with no oral work.
Name it, without deciding for them: "I am not saying that choice is a bad one. I am saying you should be able to make it once you are capable of both." It is a frequently neglected point with heavy consequences: at this age, anxiety can decide a course of study, and therefore a career. Make it a treatment goal rather than a subject of debate.
How long before a change is visible?
The first exercises produce a visible effect around session 8 or 9, that is, two months. The first six sessions prepare — the formulation, the checkable predictions, the tools — and it is normal for not much to happen before then. Announce that timetable in session 1 and in session P1, failing which the family will lose heart at exactly the moment the work begins.
Are fourteen sessions enough?
For a majority, with the two boosters. If improvement is partial, extend by four to six targeted sessions, naming what remains, rather than running the whole thing again. And be aware that the response is sometimes slightly weaker in adolescence than in childhood: the data are mixed, and the probable explanations are comorbidity and the longer standing of the presentations — which argues for treating the comorbidities and not skimping on the exposure, not for giving up.
They are doing well and they are leaving to study in another city.
That is the moment of highest risk, and it can be anticipated: the frame disappears, nobody notices the renunciations, and everything is decided in the first two weeks. Plan two or three sessions of anticipation before they leave — a specific hierarchy, a group activity begun in the first week, the errands done by them — and an appointment set for a month after the start of term. It is one of the best possible uses of this treatment.