Shorter communicationBrief cognitive therapy for social phobia: a case series☆
Introduction
Social phobia is a common and disabling anxiety disorder. In the absence of treatment social phobia can persist for a number of years. Even when psychological treatment is available, social phobia can pose complex therapeutic challenges. Evaluations of psychological treatments for social phobia show that the most effective interventions are cognitive therapy (CT) and exposure (e.g., Heimberg and Juster, 1995, Taylor, 1996). Heimberg and Juster concluded that CT alone, and exposure alone produce equivalent results. In a meta-analysis of 42 treatment outcome trials of these approaches, Taylor reported that combined CT and exposure-based methods produced significantly larger effect sizes than did CT, exposure-based methods, and social skills training alone. Nevertheless, the degree of improvement, particularly cognitive change, across these treatment modalities is variable and their implementation and delivery is both costly and time-consuming. Clark and Wells (1995) argued that psychological treatment for social phobia may be more effective if it is based on a model of the cognitive processes involved in the maintenance of this disorder. In view of this, they proposed a cognitive model highlighting specific cognitions, and maladaptive attentional and coping strategies in the perpetuation of social phobia.
In Clark and Wells’ (1995) cognitive model, it is proposed that individuals with social phobia process negative aspects of themselves on exposure to feared social situations. This self-processing usually occurs as an impression of appearance from an ‘observer perspective’, in which symptoms of anxiety and failed performance are thought to be highly conspicuous. Self-processing in social situations is also linked to the execution of safety behaviours aimed at preventing social calamities and controlling or concealing symptoms. The problem with self-processing is that it diverts attention away from processing external social information that could modify negative beliefs. Safety behaviours are problematic since the non-occurrence of catastrophe can be attributed to use of the coping behaviour so that the individual fails to discover that social situations are not dangerous. Such behaviours can exacerbate symptoms and contaminate the social situation. Aside from in-situation self-processing, individuals with social phobia are also thought to engage in pre- and post-event worry that maintains negative perceptions of the self. Recent evidence is consistent with the idea that post-event processing is elevated in socially anxious individuals (Rachman, Gruter-Andrew & Shafran, 2000).
On the basis of their model, Clark and Wells (1995) developed a new version of CT for social phobia (Wells, 1997, Wells and Clark, 1995). In brief, the treatment derived from this model is structured as a sequence in which idiosyncratic conceptualisation and socialisation are followed by manipulations of safety behaviours and self-focused attention in feared social situations in conjunction with exposure as a behavioural test of negative self-beliefs. The next step in the sequence involves modifying the content of the distorted observer perspective self-image. Strategies are also used in treatment to reduce pre- and post-event worry.
An initial evaluation of the effectiveness of this type of treatment revealed encouraging results with mean changes in fear of negative evaluation between 1.5 and 2 times greater than those reported in previous outcome trials of cognitive-behavioural therapy (Clark, 1997). More recently, Clark (1999) reported preliminary data from the Oxford randomised, placebo-controlled trial comparing the new type of CT with fluoxetine plus exposure, and placebo plus exposure. These results demonstrated that CT was significantly superior to the other treatment conditions in reducing symptoms of social phobia, including fear of negative evaluation.
In this study, we aimed to evaluate the effectiveness of a brief form of CT based on the Clark and Wells’ (1995) model. The existing treatment involves 14–18 individual sessions. In order to abbreviate this treatment, modifications were based on theory (Wells & Matthews, 1994), empirical research supporting treatment components (Harvey, Clark, Ehlers & Rapee, 2000; Wells et al., 1995, Wells and Papageorgiou, 1998, Wells and Papageorgiou, 1999, Wells and Papageorgiou, 2000), and our clinical experience in delivering the intervention.
Section snippets
Design
In order to evaluate the effectiveness of a brief form of CT for social phobia, a single case series using an A–B design (Barlow & Hersen, 1984) with follow-up was implemented. For this design, all patients were assigned to no-treatment baselines ranging from 3 to 5 weeks. Individual baselines acted as control periods, and were extended until stable trends in most outcome measures were evident. During baseline periods, the therapist met with patients weekly in order to administer and collect
Results
Patients’ SPRS scores on social avoidance, self-consciousness, and total negative belief during baseline and treatment periods, and at follow-up are shown in Fig. 1. The baseline scores on these weekly measures were predominantly stable across patients. Therefore, it is unlikely that the brief CT effects observed are the result of spontaneous recovery. Fig. 1 shows that all patients responded positively and rapidly to the brief treatment. The pattern of scores suggests that patients achieved
Discussion
The results of this preliminary case series suggest that social phobia can be treated effectively and more economically using a brief form of CT based on Clark and Wells’ (1995) cognitive model. Recent theoretical work and empirical evidence as well as clinical experience have all enabled us to extract and refine the active ingredients of CT for social phobia. The results suggest that CT may be effectively abbreviated by emphasising the modification of attentional and worry processes, and
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Parts of this paper were presented at the Annual Conference of the British Association for Behavioural and Cognitive Psychotherapies, Bristol, UK, July 1999.