Cognitive-Behavioral Therapy for Social Phobic Individuals

[This is a paper I wrote for my Abnormal Psychology graduate class. In it, I review the literature regarding cognitive-behavioral therapy (CBT) for social phobia. Social phobia, also known as Social Anxiety Disorder (which has the unfortunate acronym SAD), is a controversial diagnosis. A psychopharmacological treatment, which is often considered the "quick fix" solution by insurance groups, may do more harm than good. So what's left? CBT is the favored alternative. It is a long-term, expensive, and time-consuming treatment. As such, it works and what is invested during CBT makes the difference between feeling better and getting better.]

Cognitive-Behavioral Therapy for Social Phobic Individuals

"Among normals, the sequence perception-cognition-emotion is dictated largely by the demand character of the stimulus situation. . . [However] the paranoid patient may selectively abstract those aspects of his experience that are consistent with his preconceived idea of persecution, etc. He may make arbitrary judgments that have no factual basis. These are usually manifested by reading hidden significances and meanings into events. He also tends to overgeneralize isolated instances of intrusion, discrimination, etc."
Aaron Beck (as cited in Minuchin, 1974)

Social phobia is considered by the American Psychiatric Association (2000) to be "a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others" (p. 456). Cognitive-behavioral therapy (CBT) is the most well-documented and well-researched treatment for this debilitating anxiety disorder (Rodebaugh, Holaway, Heimberg, 2004). CBT draws upon two distinct yet inherently coupled theories which produce two types of oft-combined treatments: exposure therapy (ET) and cognitive restructuring (CR). To clarify the terminology, ET refers to exposure treatments-without explicit cognitive interventions-such as imaginal, in virtuo, and in vivo desensitization, relaxation and social skills training, behavioral experiments, and homework assignments (Rodebaugh et al., 2004; Roy et al., 2003). Conversely, CR includes explicit cognitive interventions such as the reduction of self-focused attention, lowered standards of perfection for social performance, the development of positive expectations for social encounters, the development or adjustment of social skills, and the enhancement of overall feelings of self worth (Overholser, 2002).

ET is derived from the classical conditioning paradigm. When paired a sufficient number of times throughout a sufficient amount of time, a neutral stimulus and an unconditioned stimulus will evoke equivalent responsive behaviors separately (Foa, Franklin, & Moser, 2002). This allows for the reduction of the pathological anxiety response through extinction and habituation (Heimberg, 2002). Habituation is associated with a long-term and relatively permanent change in behavior (Leaton & Supple, 1991). According to Foa et al. (2002), there are two conditions that must be met in order for this change in anxiety to be accomplished. First, the individual must be objectively and subjectively experiencing the anxiety response. Second, the information present in the environment must be perceived to be in contrast to the individual's existing unrealistic and selectively abstracted expectations.

In order for a situational expectation to develop, a previously experienced situation must be subjected to the cognitive processes of perception and reason. When it is formed, the expectation will mediate the thoughts that are had before and throughout any similar situation. This is why a non-threatening social encounter, when preceded by a history of perceived or actual threatening social encounters, may be perceived as threatening and produce anxiety.

This "threatening" perception is reinforced by a socially phobic individual's tendency, first, to believe that they will behave in an inept and unacceptable manner that will produce unbearable consequences; second, to interpret the symptoms of anxiety as additional sources of danger and anxiety; third, to become preoccupied with their anxiety and negative cognitions within the encounter; fourth, to distort and exaggerate any social cues as being negative; and finally, to interpret these "negative" cues as further evidence of failure (Clark & Wells, 1995). Because of this cyclical process, Stopa & Clark (1993) assert that ET alone does not provide long-term benefits as it is unlikely to change the patient's negative beliefs and self-defeating cognitions.

In a study conducted by Hoffman (2004), 90 social phobic individuals were assigned to a therapy group in which a modified version of Heimberg's cognitive-behavioral group therapy (CBGT) was used, an exposure therapy group without explicit cognitive interventions (EGT), or a wait-list control group. The CBGT group was trained in cognitive restructuring and rational thought processing. The EGT group received in vivo exposures, didactic training, and weekly homework assignments. Twenty-one patients prematurely ended treatment. Patients in both group treatments showed significant improvement over the control group on the Social Cost Questionnaire (SCQ) and the Social Phobia and Anxiety Inventory (SPAI) that measure patients' estimated social cost and symptom severity, respectively. Neither group treatment differed significantly from the other at post-test. However, at the 6-month follow-up, the CBGT group showed more improvement on SPAI than the EGT group.

Mattick and Peters (1988) found that a combination of CBGT and ET is superior to ET alone. In the study, 25 patients diagnosed with social phobia according to DSM-III guidelines were assigned to the combined group, while 26 patients received ET alone. Patients in the ET group were required to stay within repeated exposures until their avoidance desire had fully dissipated. Individualized lists of anxiety-invoking situations ordered from least to most feared were employed within the framework of guided exposure. Patients first engaged in those situations invoking only moderate anxiety and gradually ascended to extremely frightening situations. During each behavioral achievement test session, a therapist was present to conduct an assessment and offer support and praise.

The CBGT-ET group received ET in the same format but was required to use cognitive techniques during the exposures. Patients in the combined group received a combination of systematic rational restructuring and rational-emotive therapy and learned cognitive restructuring techniques which allowed them to assess their anxiety as the product of irrational anticipatory and in-situation processing. Pre- and post-treatments showed that the ability to complete behavioral achievement tests of all patients improved significantly. However, at the 3-month follow-up, only 17% of the ET group could complete 100% of the items listed in their fearful situations hierarchy, whereas 52% of the CBGT-ET could complete 100% of the items. Furthermore, 48% of ET group patients reported continued avoidance of feared situations whereas only 14% of CBGT-ET patients reported avoidance of feared situations.

In continuance of Mattick and Peters (1988), Mattick, Peters, and Clarke (1989) assigned 43 patients diagnosed with social phobia to one of four groups: ET, CR, CR-ET, and a wait-list control group. Results indicated that the ability of participants in the ET, CR, and CR-ET groups to complete behavioral achievement tests improved over time. All three groups improved significantly more than the waitlist control group. At the 3-month follow-up, the CR and CR-ET groups showed continual improvement whereas the gains that had been made by the ET group were reduced. The results of this study combined with the results of Mattick and Peters (1988) and Hoffman (2004) highlight the crucial impact of CBT and uphold the effectiveness of the CR-ET combination in treating individuals who suffer from social phobia.

In a review of five meta-analyses, Rodebaugh et al. (2004) found mixed results. When compared to the wait-list control groups at pre- and post-treatment, all CBT treatments of social phobia, which included ET, CR, CR-ET, and applied relaxation showed moderate to large effect sizes and continued improvement at follow-up. The meta-analyses were inconsistent in reported differences between the effect sizes of the ET and CR-ET treatments. Overall, the effect size of CR-ET was superior to the effect size of ET; however, the different did not reach statistical significance. Rodebaugh et al. concluded that CR and ET are so intrinsically related that both treatments heavily "borrow" from one another and, due to ethical concerns, should not be completely dichotomized for the purpose of a meta-analysis.

Because of the fundamental relationship between CBT treatment types, it is important in any discussion of social phobia to review the literature of non-CBT treatment types. Pharmacotherapy and technology-based treatments are two developing yet important treatment types. Regarding psychopharmacological treatments for social phobia, a single study was found. In the first phase of a two-phase study comparing CBGT and phenelzine (an MAO-inhibitor), Heimberg et al. (1998) randomly assigned 33 patients to 12 weeks of either CBGT, phenelzine treatment (PT), placebo treatment, or educational-supportive group therapy (a CBGT-equivalent placebo). At post-treatment, 77% of the PT group and 75% of the CBGT group were considered responsive to their respective treatments. Response rates for these groups were significantly higher than their placebo counterparts. Overall, compared to the CBGT group, the PT group improved faster and was more improved on a subset of measures.

In the second phase, Liebowitz et al. (1999) maintained the CBGT and PT responders for an additional 6 months of treatment and, after treatment had completely terminated, conducted a 6-month follow-up. Despite the promising gains made by the PT group, at follow-up 50% had relapsed as opposed to 17% of the CBGT group. Results have been mixed regarding combined CBT and pharmacotherapies (Heimberg, 2002; Foa et al., 2002; Rodebaugh et al., 2004).

As technology and medicine advance, so must therapy. Skinner and Zack (2004) believe that, if employed correctly, internet-based counseling and therapy is both effective and ethical. Because in vivo exposure treatment cannot be stopped easily and imaginal treatment is nearly impossible to objectively assess, virtual reality (in virtuo) exposure treatment (VRT) may soon prove to be more advantageous. Roy et al. (2003) assessed the pre- and post-test results of 10 social phobic individuals, four of which received individual VRT and six of which received CBGT. The VRT consisted of exposure to five different virtual realities. The first reality, the training reality, allowed the patient to explore a non-threatening environment and learn how to interact with the environment through the joystick and headset. In the second reality, the performance reality, the patient joins seven virtual-patients in a meeting room. The patient's tasks are to sit down in a free chair, to introduce himself, to stand up, and to present a project. In the third reality, the intimacy reality, the patient must introduce himself and have a polite conversation with virtual-patients in a decorated apartment. In the fourth reality, the scrutiny reality, the patient must enter a coffee shop, sit-down across from a friend, engage a conversation with his friend, and experience the situation of a mistake in the sum of the bill when the waiter comes to collect. Throughout this exposure, the patient is constantly being looked at by every virtual-participant.

Finally, in the fifth reality, the assertiveness reality, the patient is criticized in an elevator, must assert himself to maneuver through a hallway, and must assert himself in a shoe store wherein three virtual-patients repeatedly attempt to sell him shoes. Both groups showed improvements from pre- to post-tests in anxiety, depression, and assertiveness as measured by the Liebowitz Social Anxiety Scale (LSAS), the Zigmond and Snaith Hospital Anxiety Depression Scale (HAD), the BDI-13, and the Rathus Assertiveness Schedule (RAS). However, the authors simply reported the means and standard deviations and failed to report the appropriate statistical procedures on the data. Given this curious omission and the small sample size, any conclusion drawn from this clinical trial is purely conjecture. However, despite the limits of this study, VRT appears to be a promising and effective addition to other treatments for a variety of anxiety disorders (Wiederhold & Wiederhold, 2000).

There an important point that is present in the CR and ET comparison studies that is not made clear by the researchers. It is the distinction between feeling better and getting better. Given the enormous impact of Ellis' Rational Emotive Therapy, it is odd that any study regarding a CBT approach does not make it abundantly clear that, whereas the gains measured at post-treatment may be a function of feeling better and getting better, the gains measured at follow-up can only be a function of getting better. The phenelzine study (Liebowitz et al., 1999) is a clear indicator of this phenomenon. In my opinion, because of the nature of cognitive restructuring treatment, gains made by patients receiving ET without explicit CR are indicative of feeling better and the gains made by patients receiving CR-ET are indicative of getting better.

Psychological treatments of social phobia and anxiety should incorporate cognitive restructuring, imaginal and in vivo desensitization, relaxation and social skills training, behavioral experiments, and homework assignments into a comprehensive, time-limited cognitive behavioral therapy for the treatment of social phobia. Self-monitoring and paradoxical intention homework assignments have also been shown to be effective in the treatment of social phobia (Feeny, 2004). Regardless of the format, an increase in quality of life that is marked by a decrease of social anxiety, impairment, and depression should be the cornerstone goal of any treatment. This occurs during CBGT and has been shown to be maintained at follow-up (Eng, Coles, Heimberg, & Safren, 2001).

Important assessment measures to administer pre- and post-treatment include the SPAI, the Social Avoidance and Distress Scale (SAD), and the Fear of Negative Evaluation Scale (FNE). The SAD assesses anxiety is social situations and the FNE measures the fear of loss of social approval (Feeny, 2004). Improvement on pre- and post-treatment FNE scores is an excellent predictor of maintained functioning (Mattick & Peters, 1988; Mattick, Peters, & Clark, 1989).

Progressive muscle relaxation (PMR), an example of an applied relaxation technique, allows the patient to manage his physiological arousal within the phobic situation (Rodebaugh et al., 2004). In conjunction with PMR, breathing retraining teaches the patient how to control his panic-induced overbreathing within the phobic situation (Barlow & Craske, 1992). Training for these techniques should be conducted prior to exposure.

Some social phobic individuals lack social skills, while others can be thought of as socially inhibited (Overholser, 2002). Regardless, social skills training can allow the patient to begin to view social cues in the correct context. Throughout the training, the patient may rehearse adaptive skills that are to replace any oft-used compensatory behaviors. The development of new skills and reinforcement of old positive skills is an important aspect of therapy prior to exposure.

Exposure treatment (ET) usually begins with the development of a fear hierarchy. Anxiety-eliciting situations are rank-ordered according to the degree of anxiety elicited within each experience. The patient begins ET by experiencing in vivo or in his imagination the situations at the bottom of the hierarchy and gradual works his way up the hierarchy. To be most beneficial, it is advantageous that the client be actively-objectively and subjectively-experiencing the situation (Fao et al. 2002).

ET may occur in and out of session. An example of an out of session exposure treatment is a behavior experiment. A behavior experiment is meant to challenge irrational beliefs such as "I must be profoundly witty in conversation to be accepted by others." This irrational belief and self-defeating goal is impossible to attain and may be challenged by asking the patient to eavesdrop on multiple lunch conversations at his workplace (Heimberg, 2002). Throughout the day and, more specifically, after a behavioral experiment, patients should self-monitor their experiences by recording the frequency, duration, and details of the situation as well as the symptoms and levels of anxiety and enjoyment that are produced by the situation (Clark & Wells, 1995).

Cognitive restructuring (CR) is a powerful component of CBT. Research has shown, that, when used as a precursor to exposure, the effectiveness of ET increases (Overholser, 2002). Patients should learn to challenge and test anxiety provoking and promoting thoughts and replace such thoughts with positive and rational thoughts. Patients must be made aware that they are not the center of attention in most social situations, and that a mistake or failure may simply go unnoticed. Behavior experiments may be designed to accentuate these strategies and augment change. For example, while at a bar, a patient may be preoccupied with spilling his drink. He may feel that spillage will have disastrous consequences. At the correct point in therapy, he should be challenged to visit a bar, spill his drink, and observe the consequences. Consequently, he should begin to escape his self-focused attention and focus on his environment and the actual social cues present. However, he should be made aware that social disapproval is an unavoidable dynamic of any social situation. As stated previously in this paper, the goals of CR should include the reduction of self-focused attention, lowered standards of perfection for social performance, the development of positive expectations for social encounters, and the enhancement of overall feelings of self worth.

The most important dynamic of the therapeutic experience is the working therapeutic alliance. The CBT notion of collaborative empiricism introduced by Beck (1976) must be upheld by a strong alliance. CBT is not simply a stodgy, manual-driven therapy. The thoughts, experiences, and identity of the patient are challenged throughout. Because of this and the patient's experiencing of situations which he views as threatening-possibly even life-threatening, rapport is absolutely necessary in order for the client to trust the therapist and believe that he may improve by following the guidance and instruction of the therapist.

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