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.

Greek Versus non-Greek: A Comparison of Attitudes Toward Homosexuality

According to the Center for the Study of the College Fraternity (2000), an average of 17.50% of students per campus are either active members of or pledging into the Greek system. Research into the attitudes toward homosexuality of student members of social Greek societies (fraternities and sororities) has been limited. An ethnographic study conducted by Rhoads (1994) revealed a connection between negative attitudes towards lesbians, gays, and bisexuals (LGBs) and membership in a social Greek society. Further ethnographic research conducted by Rhoads (1995) at a fraternity house revealed that oppressive acts towards homosexuals serve to reaffirm masculinity. Rhoads’ conclusion supported the findings of Sanday (1990) who argues that fraternity members may be hiding “…a deep fear, hatred, and fascination with homosexuality” (p. 122).

Other research suggests that there is no empirical connection between Greeks and non-Greeks and negative attitudes toward homosexuals. With 692 heterosexual students at six liberal arts colleges participating, Hinrichs and Rosenberg (2002) investigated attitudes toward homosexuals and homosexuality as a function of Greek affiliation, sex role attitudes, and contact with and knowledge of LGBs. The researchers found that students who tended to be female with liberal sex role attitudes and positive contacts with LGBs were more accepting of LGBs. The results indicated that on campuses with social Greek societies, Greeks did not have significantly more negative attitudes toward homosexuals than non-Greeks. However, campuses with no social Greek societies had significantly more positive overall attitudes toward homosexuality than campuses with social Greek societies.

Kuriloff and Lottes (1994) investigated the extent to which gender, time in college, and membership in a social Greek society influenced students’ political and social attitudes. The researchers measured attitudes regarding liberalism, social conscience, feminism, male dominance, and intolerance of homosexuality. Subjects were students at an eastern United States university. A questionnaire was mailed to freshman students living in a dormitory in 1987. The same questionnaire was mailed again in 1991 to the same students who were still enrolled at the university. Of the 303 students who completed both surveys, 135 were males, 168 were females, and 35% reported membership in a social Greek society. The results indicated a substantial overall decrease of intolerance of homosexuality for all participants from 1987 to 1991. However, Greeks were not more intolerant of homosexuality than non-Greeks. The researchers concluded that Greek affiliation has little impact on student attitudes over time. Additionally, the researchers concluded that, because only a limited amount research has been conducted on the social and political attitudes of Greeks and non-Greeks, empirical support for the hypothesis that Greeks are more intolerant of homosexuality as compared to non-Greeks may exist.

In a similar study, Pratte (1993) examined differences in attitudes of males and females, college students and non-college students, and subjects of various age groups toward homosexuality. In 1986 and again in 1991, a questionnaire was distributed to 90 randomly chosen subjects. Of the 180 participants, 90 were male and 90 were females. Seventy-five were undergraduates enrolled at a university in the midwest and 105 were from a rural community. Similar to the findings of Lottes and Kuriloff, the results indicated that subjects surveyed in 1986, male subjects, and non-student subjects expressed significantly stronger anti-homosexual attitudes than subjects surveyed in 1991, female subjects, and college student subjects.

An increase in tolerance of homosexuality among college students over a period of time may be a function of proximity and past exposure. Bowen and Bourgeois (2001) hypothesized that knowing LGBs prior to college would contribute to more positive attitudes towards homosexuality. Second, they hypothesized that regardless of past exposures, contact with LGBs in student’s residence halls would result in attitudes that are more positive. Finally, the researchers hypothesized that students would rate their own attitudes as more positive than those of friends or of typical students. Subjects for the study were undergraduates living in two similar coed dormitories in close proximity. One hundred and nine students recruited by mail completed the researchers’ survey. Fifty-one were male and 58 were female. The researchers found that there was a significant positive correlation between the number of homosexuals known before college and current level of comfort with homosexuals. Student’s comfort ratings were significantly higher when they reported LGBs living within their residence hall. Student’s comfort ratings were also significantly higher when they reported LGBs living on their floor. Personal comfort with homosexuals was rated significantly higher than the perceived comfort of their friends and higher than a “typical” student’s comfort. Findings indicated that students who had more exposure to LGBs before college felt more comfortable with LGBs when compared to those with less or no pre-college exposure. However, regardless of past exposure, students who reported LGBs living on their halls or on their floors felt significantly more comfortable than students who reported not knowing any close-proximity LGBs.

In a similar study, Herek and Capitanio (1996) obtained similar results from a two-wave national telephone survey. Subjects were randomly selected and were telephoned between 1990 and ‘91 and were telephoned again one year later. Participants indicated their attitudes toward gay males during the first wave and attitudes toward gay males and lesbians during the second wave. Findings were generally similar between both waves and revealed that heterosexual participants with contact with gay males had more positive attitudes toward gay males than those without contact. Those with more and closer relationships had more positive attitudes toward gay males.

Louderback and Whitley Jr. (1997) attempted to explain why males tend to tolerate female homosexuality more so than male homosexuality. They theorized that males place a high erotic value on lesbianism, place a low erotic value on male homosexuality, and have more “traditional” sex-role attitudes. They further theorized that concurrent control of the perceived erotic value of homosexuality and sex-role attitudes would reveal that males have similar attitudes toward lesbians and gays. Subjects were undergraduates from a university in the midwest. Of the 167 subjects surveyed, 58 were males and 109 were females. Participants completed a test booklet in classrooms in same-sex groups of 5 to 20 individuals. Attitudes toward homosexuals were measures by the Attitudes Toward Lesbians and Gay Men (ATLG) scale, a 20-item survey created by Herek (1984). The instrument includes two subscales, the Attitudes Toward Lesbians (ATL) and Attitudes Toward Gay Men (ATG) scales. An 8-item instrument developed by the researchers measured the perceived erotic value of homosexuality. Two subscales, one referring to lesbian sexuality and one referring to gay male sexuality were comprised of four items each. Sex-role attitudes were measured by the 30-item Attitudes Toward Roles of Men and Women (ATRMW) scale. This instrument has two subscales of 15 items each: the Attitudes Towards Women (ATW) and Attitudes Towards the Male’s Role (AMR) scales. The data revealed that females responded similarly on the ATLG and the perceived erotic value of homosexuality measures. On the other hand, males were more tolerant of lesbian sexuality and perceived it to be more erotic and they were less tolerant of gay male sexuality and perceived it to be less erotic. However, when the perceived erotic value and sex-role attitude scores were controlled for both males and females, the adjusted means closely resembled each other. Female’s scores remained nearly unchanged. However, scores for males were similar to females’ scores towards lesbians and gay males as measured by scores on the ATLG. The researchers concluded that because heterosexual males do not view gay male homosexuality as erotic, heterosexual males may be more likely to discriminate against gay males. Heterosexual females do not view either lesbian or gay male sexuality as erotic and therefore may discriminate equally against both.

In addition to overt intolerance, college students may be unwittingly intolerant of homosexuality. Aberson, Emerson, and Swan (1999) hypothesized that because the descriptor “gay male” may cause a desire to appear sympathetic, participants will overcompensate and prefer a gay male to a straight male in a controlled situation. Bias against a gay male will only become apparent when there is an opportunity to express negative feelings toward gay males in situations where there exists a justification that is not based on sexuality. Participants were undergraduates attending various small, private colleges in southern California. Of the 260 participants, 113 were males and 143 were females. Four subjects did not indicate gender. Participants were randomly assigned to one of four conditions: heterosexual-no justification (55), gay-no justification (51), heterosexual-justification (76), and gay-justification (78). Each group was told that their evaluations of an applicant for a new HIV-AIDS education program would affect the hiring process. The duration of the interview videos was five minutes. The actor described himself as acquiring HIV from a brief but sexually intense relationship with either a man or woman depending upon the condition. In bother justified bias conditions, when asked, “Why do you feel college students can relate to you?” the actor answered, “Look, I was a college students. I know how completely stupid and totally naïve college students are.” In both unjustified bias conditions, the actor answered, “Look I was a college student.” Participants were fully debriefed and duplicity was revealed after participation in the study. The evaluation measure was a 29-item instrument. Subjects responded to items on 7-point scales. The instrument included two subscales: 19 items that indicated positive traits and 10 items that indicated negative traits about the interviewee. A 7-item instrument measured attitudes toward homosexuals. Subjects responded to these items on 5-point scales. The results revealed that the gay male was rated significantly more favorable overall than the heterosexual male. The gay male in the justified bias condition was more favored than the heterosexual male in the same condition. The researchers found that participants did not rate the gay male negatively regardless of condition. However, the gay male tended to be rated higher on negative trait items and the heterosexual male in the no justification condition tended to be rated higher on positive trait items. The findings led Aberson et al. to conclude that there was evidence of a covert form of bias in which the participants elevated the heterosexual man and did not diminish the gay man.

While many strides have been made to afford homosexuals equal rights, prejudice, discrimination, and victimization still exist. In a study conducted by Norris (1992) at Oberlin College, findings indicated widespread victimization of LGBs. A survey distributed by mail was completed by 869 students of whom 26.3% of females and 15.7% of males claimed a lesbian, gay, or bisexual sexual orientation. Of the two groups, 80% of females and over 70% of males either had denied their sexual orientation or were verbally insulted for being perceived as homosexual. On the other hand, 95.5% of students supported the active campus presence of LGBs. Norris theorized that this paradox results from support of equal rights by a majority but the practice of equal rights by a minority.

Due to the lack of prior research in this area and due to the high rate of victimization of homosexuals, the purpose of this study is to examine attitudes towards homosexuals as a function of Greek affiliation. The researcher hypothesized that Greeks would score significantly higher on measures of intolerance towards homosexuality than non-Greeks.

Christian Dominionism is the powerful political arm of Christianity. The end of abortion, gay marriage, and birth control and the regulation of personal behavior are among the goals Dominionism. Dominionism is not just another fundamental Christian lobby. Dominionists have enjoyed unparalleled and unprecedented access to the White House during Bush 43′s tenure.

The figureheads of the Dominionist movement are James C. Dobson of Focus on the Family and Tony Perkins of the Family Research Council.

James C. Dobson:

[James C.] Dobson is now America’s most influential evangelical leader, with a following reportedly greater than that of either Falwell or Robertson at his peak.

Dobson earned the title. He proselytized hard for Bush this last year, organizing huge stadium rallies and using his radio program to warn his 7 million American listeners that not to vote would be a sin. Dobson may have delivered Bush his victories in Ohio and Florida.

He’s already leveraging his new power. When a thank-you call came from the White House, Dobson issued the staffer a blunt warning that Bush “needs to be more aggressive” about pressing the religious right’s pro-life, anti-gay rights agenda, or it would “pay a price in four years.”

[In 2004], Dobson started a new offshoot of Focus on the Family called Focus on the Family Action, which he used to campaign openly for Bush. And during the campaign he joined Ralph Reed and…Charles Colson in regular conference calls with Karl Rove and other senior White House officials.¹

Focus on the Family:

Focus on the Family (FOTF or FotF), founded in 1977, is a Christian non-profit organization based in the United States. The organization describes itself as “dedicated to nurturing and defending families worldwide”. The group was founded by James Dobson and is headquartered in Colorado Springs, Colorado. Focus on the Family is one of a number of evangelical para-church organizations whose stated aim is not to start a new church or denomination, but to work interdenominationally to protect and promote their definitions of traditional family and family values. Some of the core promotional activities of the organization include a daily radio broadcast by Dobson and his colleagues, providing free counseling and resources for those facing family difficulties, and publishing a variety of magazines, videos and audio recordings.²

Tony Perkins:

From 1996 to 2004, Perkins was a member of the East Baton Rouge delegation to the Louisiana House of Representatives, where he served as a Republican. Republican Perkins ran for the United States Senate in the 2002 Louisiana jungle primary and received 10 percent of the vote. Perkins became the President of the conservative Christian Family Research Council, a political offshoot of James Dobson’s Focus on the Family in September 2003.³

Family Research Council:

The Family Research Council (FRC) is the powerhouse of Christian influence in Washington. Founded in 1983 by Dr. James Dobson of Focus on the Family, the FRC is led by former Louisiana state representative Tony Perkins. The FRC reportedly has the ear of many members of Congress, the White House, and Christians nationwide. FRC is actively involved in educating religious leaders about moral issues being affected by decisions in Washington, and also in representing those leaders directly to the decision makers themselves. You will find them well represented on news channels and radio stations nationwide, and at meetings where key strategies are planned.⁴

This post has four sections, the first three of which include related statements by Dominionists and rebuttals by respected researchers.

In a review of unclassified United States government data, Denbeaux et al. (2006) concluded that, of the 517 “unlawful combatants” detained at the Guantánamo Bay detention camp for more than four years, 55% had not been charged with engaging in hostilities against the United States or its coalition allies and 60% are detained for being “associated with” one or more terrorist organizations. Additionally, “[o]nly 8% of the detainees were characterized as al Qaeda fighters. Of the remaining detainees, 40% have no definitive connection with al Qaeda at all and 18%…have no definitive affiliation with either al Qaeda or the Taliban” (Denbeaux et al., 2006, p. 2).

In 2005, a small group of civilian medical professionals, which included New England Journal of Medicine contributing editor Dr. Susan Okie, visited the Camp Delta to be briefed by the commander of Guantánamo Bay, Major General Jay W. Hood, on the current state of the medical and mental health care provided to the detainees. Because of safety and privacy concerns, the group was not permitted to see or talk to the detainees (Okie, 2005). Of main concern to the group was the possible involvement of medical personnel in the mistreatment of the detainees. Specifically, the group was curious about the Behavior Science Consultation Team (BSCT, pronounced “Biscuit”) program.

The BSCT program began in 2002 and was approved for use at Guantánamo Bay by then commander Major General Geoffrey Miller to develop behavioral and psychological strategies that would expedite the gathering of intelligence from the “more than 100 detainees considered to have high intelligence value” (Okie, 2005, p. 2532). The BSCT at Guantánamo Bay included a psychiatrist and a psychologist who “prepared psychological profiles for use by interrogators [and]…sat in on some interrogations, observed other from behind one-way mirrors, and offered feedback to interrogator” (Bloche & Marks, 2005a, p. 7). The role of the BSCT medical personnel in the abuse of Mohammed al-Qahtani, a detainee determined to be of high intelligence value, is well documented (Miles, 2007)