The nature of relationship in CBT is one of collaborative empiricism. The term refers to the scientific or experimental nature of the approach to solving problems in therapy. Thus, in therapy, the therapist does not assume that he/she already knows better than the adolescent. Prescribing solutions or deciding for the adolescent is avoided. They work jointly on the discovery of dysfunctional patterns in thinking, setting goals and deciding on activities. Collaboration is to be followed at all points in therapy. This includes the start of therapy at which point goals are set. Thus, therapy is a joint effort between the adolescent and the therapist and the family as well.

When working with adolescents, it is important to involve parents at various points in the intervention and to keep the adolescent informed. This is particularly relevant in anxiety management, wherein parents are either cotherapists, facilitators or are part of the intervention due to their role in maintaining anxiety.

CBT involves the acquisition of skills for new patterns of thinking and coping. An important way of achieving this is through practice. Homework compliance has been found to be a major predictor of treatment outcome. Factors such as poor understanding of the therapy, anxiety, cognitive distortions and inadequate motivation/opportunities affect compliance. The therapist must be aware of these factors and work on them to ensure that compliance is maintained. CBT in adolescents involves the use of activities, worksheets and various other methods of communicating formulation, educating and increasing participation.

Several ethical concerns arise in the treatment of children and adolescents. These are governed by the basic ideas of do no harm, doing what is in the best interest of the child or adolescent and protecting the privacy of the child or adolescent. Respecting the child and family without any bias and promotion and supporting the highest level of development and autonomy in the child are some of the other important rules (Schetky 1995). The therapist additionally faces pressures to control the child and force compliance at the cost of the individuality of the client.

Several other concerns arise in working with adolescents. It is important to protect the privacy of the adolescent client and keep him/her informed about frequency of parent involvement. The exceptions to the rules of privacy and confidentiality are also to be made clear to the adolescent.

Ascherman and Rubin (2008) provide an excellent discussion about current ethical concerns in the practice of child and adolescent psychotherapy.

The threefold aim of CBT is (a) symptom reduction, (b) belief modification or identification and modification of unhelpful thinking and (c) preventing relapse. Thus, CBT shares certain common strategies that help achieve these goals. Depression and anxiety in adolescents are two major mental health concerns.

A brief overview of some of the frequently used therapeutic strategies are described here.

Several cognitive and behavioural strategies have been found to be effective in adolescents. The choice of strategies is based on the case conceptualization and the functional analysis of problems. Rationale for each of the strategies must be established clearly, as also the monitoring of progress once they are implemented. Continuous monitoring by the therapist and adolescent also allows for the detection of changes and responses and allows the therapist to alter or change treatment strategies.

In the following section, a few frequently used strategies are briefly described. They are further described in the later sections of this chapter, in the context of conditions for which they have been found to be effective.

Arousal reduction methods: Anxiety or arousal reduction is an important therapeutic goal as it leads to symptom reduction. Several different types of strategies can be used to help the adolescent client reduce arousal or anxiety. They include deep muscle relaxation, biofeedback procedures (EMG and galvanic skin response), deep breathing and Eastern methods such as Shavasana and mindfulness-based stress reduction programmes. These methods have also been found to be helpful in anger management and help the adolescent in coping with anxiety and anger by teaching them self-regulation. Arousal reduction methods are most effective when practised regularly.

Applied relaxation (AR) (Öst 1987): The need for more portable and briefer methods of producing the relaxation response in anxiety management led to the development of the AR. It was first described by Chang-Liang and Denney (1976) and later developed by Öst (1987). AR is described as a coping skill, which has several steps. They include recording and identifying early signs of anxiety or worry that act as cues for anxiety and training in deep muscle relaxation or tension release relaxation (sessions 2 and 3), followed by release-only relaxation (session 4) and cue-controlled relaxation (session 5) in which the word cue or calm is paired with exhalation, differential relaxation and rapid relaxation (session 8). Sessions 10–11 are focused on application of these skills to actual situation, based on the cues recorded by the client. Finally, the client and therapist review the overall programme and its maintenance. AR has been found to be particularly effective in panic disorder, generalized anxiety disorder and social phobia.

Exposure and Response Prevention (ERP) is a treatment of choice in the management of OCD. It is based on the theoretical principle of habituation and extinction. ERP involves drawing a hierarchy of situations or triggers that provoke anxiety/fear/disgust, by collaboratively working with the adolescent. The situations/triggers are rated for their subjective units of distress (SUD). The adolescent may also be asked to state what would happen if he/she did not perform the neutralizing behaviour or compulsion so as to understand underlying beliefs. Systematic exposure to these cues is started with items that elicit moderate amounts of anxiety and the adolescent is asked not to engage in compulsions either overt or covert, till there is a significant reduction in anxiety (usually at least 50 %). This allows for habituation of the experience of anxiety, and with repeated practice, there is an extinction of the response of anxiety, even in the presence of these triggers. During the practice of ERP, the therapist must ensure that the adolescent has understood the rationale for response prevention, as well as the need to be able to tolerate distress that arises during exposure. Sufficient education regarding the symptoms, role of neutralizing behaviours in maintaining distress and beliefs is to be carried out before beginning ERP. This not only ensures adequate compliance but is also likely to be helpful in reducing attrition.

Adequate time for exposure is crucial factor in the practice of ERP. Insufficient or brief exposure can result in the enhancement of anxiety or inadequate learning. The therapist is also alert to use of cognitive compulsions in place of overt ones, avoidance or other subtle forms of neutralizing behaviours and this can be seen when clients report sudden decreases in anxiety.

Graded exposure is a behavioural strategy based on the learning principle of habituation and extinction. It is the treatment of choice in the management of specific phobia, panic disorder, social phobia and other anxiety disorders. Graded exposure addresses avoidance and fear, by systematic exposure to fear-evoking stimuli. The therapist and client prepare a hierarchy that includes fear-evoking situations or triggers and the level of anxiety or fear (subjective unit of distress). Based on this list of situations, the client is gradually exposed to cues, allowing for habituation to occur and subsequently extinction of fear.

Social skills training (SST) is a skills-based programme developed on the principles of social learning. SST assumes that social skills can be learned and acquired with training. Skill deficits in adolescents account for several emotional and behavioural problems such as anxiety, anger, poor interpersonal relationships and overall adjustment leading to stress. SST focuses on building verbal and non-verbal skills that are essential in initiating and maintaining interpersonal skills. Assessment plays a very important role in setting goals for SST. It includes both self-report and observation and behavioural data. Role-play and modelling are some of the important methods by which SST is imparted. Steps in SST include establishing a rationale for skill acquisition, discussing steps involved, modelling skill in role-play, reviewing role-play, engaging the client in a role-play of the same situation, providing positive and corrective feedback and finally assigning homework that will help consolidate gains. Repeated practice and practice across different situations are essential in making SST effective.

Assertiveness skills are an important component of SST and use role-play and modelling to teach skills in effective expression of positive and negative emotions. Assertiveness skills training involves training in refusal, requesting skills, accepting positive or commendatory feedback. In adolescents, assertiveness is particularly important for resisting peer pressure for risky behaviours such as sexual behaviours or substances.

PSST (D’Zurilla 1986): The absence of adequate problem-solving skills often results in the build-up of stressful states and subsequently anxiety and depression. Problem-solving skills are particularly helpful in adolescents who experience various sources of stress such as academic, peer-related and family. Steps in PSST are (a) orientation or set to formulate problems as potentially solvable. This includes the recognition of a problem and the ability to resist taking an action impulsively. (b) Problem definition in which the central element is specificity as one must be precise, and specific (e.g. I have difficulty in getting to know people socially) (c) generate alternate courses of action: by using brainstorming and other such procedures) decision-making (e.g. refusing to go out with a friend where pressure to drink is high) (d) verification requires that the client be able to anticipate, rehearse and implement a decision. Here, social skills are required or even detailed anticipation of events in the person’s life followed by a debriefing after these schedules are implemented. Thus, PSST is a cognitive behavioural programme.

In addition to these broad strategies, cognitive restructuring and many other behavioural strategies such as stimulus control (for study skills, weight management), behavioural activation (in depression) and self-instructional training may be incorporated into programmes that target specific problems.

Depression in youth and adolescents is a major concern for mental professionals, and nearly 1.5–8 % young adults (from late adolescence) suffer from depressive disorder (Rushton and Schectman 2002; Waslick et al. 2003). CBT is considered to be one of the most efficacious treatments for depression (Waslick et al. 2003), with a significant amount of evidence supporting it (TADS 2003; Kaufman et al. 2005).

Cognitive models of depression in older children and adolescents recognize that by around ages 8–11 years, most children can both identify and report several cognitions that are seen in adults (Harrington 2005). This is also the time when children are able to perceive self psychologically as well as understand the meaning of events such as death, separation or loss. The nature of presenting complaints appears to be a significant positive indicator for CBT in adolescents. Thus, adolescents who present with a primary problem of mood or depression appear to be more suited for CBT. In addition, the recognition and acknowledgement of the problem by the adolescent and family serve as positive indicators for the choice of CBT. When the family acknowledges the presence of depression and the need for psychological intervention, they will also assist and support the adolescent in therapy.

Contraindications include the developmental stage of the adolescent, severity of depressive symptoms and the social context. With respect to the developmental stage, many techniques used in CBT require knowledge about thought processes or cognition (metacognition). Therefore, if the adolescent is not able to do this, carrying out homework and other tasks will be difficult. The social context is an important factor in response. Many adolescents are caught in social contexts that are difficult to alter, and therefore, despite psychological treatments, problems may ensue. There is a little research on the role of comorbid disorders in impacting outcome of CBT in adolescents.

Anxiety disorders and other internalizing disorders form a major part of the psychiatric disorders seen in children and adolescents. Although many fears and anxieties may be transient, changing as the child grows up, others continue, developing into debilitating problems. OCD, social anxiety, specific phobia, school refusal and panic attacks are common anxiety disorders seen in adolescence.

Social phobia is known to have onset in childhood or adolescence; however, very often social anxiety goes unrecognized. This has resulted in far more research on adult samples than in adolescents. The presentation of social phobia is also likely to be different in adolescents, with greater externalizing and antisocial problems, excessive self-focused attention and avoidance (Kashdan and Herbert 2001).

Cognitive behavioural management of anxiety disorders assumes a multicomponent etiologic, involving biological, psychological/cognitive and behavioural components. The treatment that follows this understanding of anxiety disorders employs a group of techniques that try to break the vicious cycle of physiological responses, fear and safety behaviours. It is important to note that anxiety disorders also have comorbid depression, which may impact treatment outcomes.

CBT for depression and anxiety shares many common strategies. An overview of these main strategies is provided below with reference to depression and anxiety.

Education and engagement is an important stage in CBT. Depending upon the severity of depressive or anxiety symptoms and existence of comorbid disorders, the process of engagement can vary in terms of time and difficulty. The process of engagement can be challenging, particularly with difficult adolescents.

CBT for anxiety disorders in adolescents includes an educational component in which the therapist provides information about the role of biological processes in the maintenance of anxiety and skills training which would help the adolescent identify the early signs of anxiety through self-monitoring.

Behavioural activation through activity scheduling aims at increasing activity levels as well as enhancing mastery and pleasure, thereby improving mood. This is particularly important in depression wherein low motivation and activity could be a presenting complaint as well as in anxiety disorders in the form of avoidance. This is achieved through pleasant events as well as tasks that are graded in terms of difficulties. In anxiety disorders, activity schedules can also incorporate tasks that have been previously avoided and provoke anxiety.

Self-monitoring (thought diary) is used to identify these patterns of dysfunctional thinking, and through this activity, the adolescent is helped to gain an understanding of the vicious cycle between thoughts, emotions and behaviours. Exposure, role-plays and other behavioural methods are also helpful in eliciting dysfunctional cognitions.

Cognitive restructuring is a key component of CBT and aims at identifying and modifying typical patterns of dysfunctional thinking that maintain depressed affect and reduce social behaviours. The process of restructuring dysfunctional patterns of thinking involves both verbal and behavioural strategies. Verbal reattribution techniques include using a cost–benefit analysis, developing a pie chart to understand the various factors that lead to a predicted outcome (error of personalization) and identifying the use of double standards to challenge excessive self-criticality, all of which are aimed at taking a more rational perspective. Behavioural reattribution techniques include behavioural experiments, role-plays, exposure sessions and poll surveys. These strategies complement the verbal strategies and also aim at cognitive change.

Learning relaxation skills help manage arousal symptoms. Several types of relaxation skills have been found to be helpful including deep muscle or progressive muscle relaxation, deep breathing, guided or positive imagery and biofeedback. Behavioural strategies are also helpful in the reduction of anxiety and are based on the learning principles such as habituation and extinction and social learning. These include, in session exposure, role-play and modelling, imagery-based methods and graduated exposures (or step ladders). For specific anxiety, symptoms such as worry and worry management techniques can also be recommended. These include worry postponement, worry exposure and prevention of worry behaviours such as checking and reducing reassurance by seeking help from the parents. Cognitive components of the anxiety management programme include identification of negative cognitions that are frequently encountered in anxiety disorders or anxious self-talk. The use of coping self-statements has been recommended to deal with anticipatory anxiety. This is carried out through the use of self-statements and cognitive restructuring that can address misinterpretation of anxiety symptoms and catastrophization.

PSST is a core component in the depression treatment protocol for adolescents (Kazdin 2002). It has also been found useful in the management of anxiety disorders. In both conditions, it can effectively prevent relapse. In depression, PSST is based on the assumption that deficits in interpersonal problem-solving skills contribute to and maintain depressive symptoms. It includes skills for interpersonal or social problem-solving, such as dealing with peers, conflicting relationships within the family and dealing with everyday problems that can potentially generate stress in adolescents. Social problem-solving allows the adolescent to anticipate and deal with situations as well as learn to respond to social cues (others’ anger, sadness) and also helps in negotiating interpersonal problems that are common in this period. The steps in PSST are similar to those in adults, beginning with identifying a problem that is to be solved, generating as many potential solutions as possible, without at this point judging quality of solutions, choosing the best options while keeping backup solutions, implementing based on skills and resources and finally reviewing outcomes.