Shorter communicationEffectiveness of cognitive behavioural group therapy for social phobia in a community clinic: A benchmarking study
Introduction
Social phobia is characterised by a fear of negative evaluation within social or performance situations, where the individual is under scrutiny and may be embarrassed (American Psychiatric Association, 1994). Epidemiological studies have shown that social phobia is common, unremitting without treatment, and debilitating (e.g. Andrews, Henderson, & Hall, 2001). Moreover, only a minority of individuals with social phobia seek treatment, and few seek an empirically supported treatment (Andrews, Issakidis, & Carter, 2001). Cognitive behavioural therapy (CBT) has been shown to be efficacious in treating social phobia in numerous randomised controlled trials (RCTs; Butler, Chapman, Forman, & Beck, 2006). Efficacy studies prioritise internal validity and thus typically adhere to strict inclusion and exclusion criteria, are well controlled, use well-trained and regularly supervised therapists, and monitor adherence to manualised protocols. However, dissemination of empirically supported treatments has probably been impeded by the perception that efficacious treatments will be less effective with more severe and complex cases seen within mental health clinics (Barlow, Levitt, & Bufka, 1999).
Benchmarking strategies have been used to compare outcomes from efficacy studies with naturalistic settings for depression (Merrill, Tolbert, & Wade, 2003), panic disorder (Wade, Treat, & Stuart, 1998), obsessive–compulsive disorder (Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000), with heterogeneous groups (McEvoy & Nathan, 2007), and in private practice (e.g. Gaston, Abbott, Rapee, & Neary, 2006). However, few studies have examined the transportability of CBT for social phobia. Haug et al. (2000) found significant improvement following exposure therapy within a general practice setting. However, results were not directly compared with previous benchmarks and the study had a number of RCT qualities, such as excluding those with comorbid Axis I diagnoses and partial recruitment via newspaper advertisements. Lincoln et al. (2003) evaluated the generalisability of cognitive behavioural individual therapy (CBIT) for social phobia to naturalistic clinical settings by benchmarking outcomes to meta-analyses and previous effectiveness and efficacy studies. These researchers found effect sizes of a similar magnitude, thus concluding that CBIT can be transported to the field of mental health. Lincoln et al. (2003) also found that applying exclusion criteria commonly used in efficacy studies did not improve treatment outcome. Similarly, Gaston et al. (2006) found that cognitive behavioural group therapy (CBGT) for social phobia was transportable to private practice.
CBGT is more effective than placebo controls (Taylor, 1996), and as efficacious as CBIT (Fedoroff & Taylor, 2001). Moreover, CBGT is considered to be the treatment of choice for social phobia, because CBIT is less time- and cost-effective (Heimberg, 2001). Additional therapeutic benefits to group treatment include normalisation of symptoms, learning from others’ experiences, a social context within which to practice skills, and social pressure to comply with treatment and complete homework. In contrast, potential logistical and therapeutic problems with CBGT have been postulated, such as patients having to wait longer as groups are arranged, less flexibility with regard to scheduling sessions, and less individualised treatment strategies (Scholing & Emmelkamp, 1993; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003). In order to assess the potential impact of these factors, Stangier et al. (2003) conducted an RCT to compare the effectiveness of CBIT to CBGT for social phobia. Patients allocated to CBIT achieved larger effect sizes on measures of social phobia, but were comparable to those receiving CBGT on measures of mood and general symptomatology. Attrition was also comparable, suggesting that the reduced flexibility of groups was not detrimental to attendance.
Few studies have evaluated the transportability of CBGT for social phobia to community mental health clinics (CMHCs), where patients are typically referred by medical practitioners and are highly comorbid, and treatment programmes are less controlled than efficacy studies. Therefore, the first aim of this study was to benchmark treatment outcomes from CBGT in a community clinic to previous efficacy and effectiveness studies of CBGT and CBIT for social phobia. It may be expected that CBGT in real-world settings will be less effective than in research settings. The second aim was to partially replicate and extend Lincoln et al.'s (2003) study by examining the effect of moderate to severe depression, age above 50, comorbid anxiety or affective disorders, or student samples, on outcomes. In addition, the effect of potentially harmful levels of alcohol consumption was examined.
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Participants
A total of 153 consecutive admissions with social phobia commenced CBGT between 2004 and 2006 (see Table 1). Exclusion criteria include concurrent schizophrenia, schizoaffective disorder, organic brain dysfunction, or a level of substance use judged by the assessing clinician as likely to interfere with engagement in treatment. While all patients with a primary diagnosis of social phobia were encouraged to attend the group programme, those who were unable or unwilling to attend weekly 4-h group
Selection of benchmarking studies
Comparison studies were required to (a) comprise adults with social phobia, (b) use CBT with cognitive restructuring and exposure components, (c) use the SPS and SIAS as outcome measures for direct comparisons, and (d) include a range of treatment formats (group, individual) and study designs (efficacy, effectiveness). Seven recent studies were identified (Table 1).
Treatment and patient comparisons
The treatment in this study had fewer but longer sessions than comparison studies, required less hours per client than individual
Discussion
The first aim of this study was to benchmark outcomes from CBGT for social phobia in a CMHC to outcomes from previous efficacy and effectiveness studies of CBGT and CBIT. Findings from this study strongly suggest that CBGT for social phobia is effective within real-world settings. The finding that CBGT compares well to CBIT is important, because CBGT requires substantially less therapist hours per patient and thus may be preferred in community clinics where resources are scarce. Moreover,
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