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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 18
A Cognitive Model for Treating Social Phobia

CEU Question 18 | CEU Answer Booklet | Table of Contents | Phobias
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs, Nurse CEUs

Social phobia, a relatively obscure disorder, is receiving increased attention due to evidence suggesting that it is more prevalent and debilitative than once thought. The purpose of this article is to help counselors better understand the nature of and treatments for this disorder. Effective behavioral and pharmacological approaches are reviewed, and counseling implications are discussed to increase counselors' confidence in providing treatment to people with social phobia.

Social phobia is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association [APA], 1994), as "a marked and persistent fear of social or performance situations in which embarrassment may occur" (p. 411). Rapee and Heimberg (1997) suggested that social phobia can best be understood on a continuum where shyness is at one end of the spectrum (indicating mild social anxiety), social phobia is in the middle (moderate social anxiety), and avoidant personality disorder is at the other end (severe social anxiety). However, the severity of social phobia should not be underestimated because evidence suggests that it is prevalent (Kessler et al., 1994), often considered chronic (Davidson, Hughes, George, & Blazer, 1993), and can be disabling to those who suffer from it (Wittchen, Stein, & Kessler, 1999). Approximately 60% of people with social phobia experience other troubling disorders, such as depression and obsessive-compulsive disorder (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992), and are at greater risk of experiencing suicidal ideation and suicide attempts (Davidson et al., 1993).

Furthermore, despite the fact that those with social phobia report that it significantly interferes with their lives, less than 20% seek professional help (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996; Wittchen et al., 1999), and only approximately 6% reported having used medications to treat their disorder (Schneier et al., 1992). The lack of information made available to people with social phobia about treatment options coupled with their fear of social interactions, including making contact with helping professionals, are cited as primary reasons for low treatment use.

The ramifications for those who must deal with social phobia are widespread and pervasive. When compared with people who had no psychiatric disorder, those with social phobia were less likely to marry and more likely to receive disability or welfare assistance (Schneier et al., 1992). In a study conducted by Wittchen et al. (1999), approximately one fifth of individuals with social phobia reported missing school and/ or work because of their condition, and 24% reported diminished work productivity. Thus, these individuals are likely to experience a wide range of psychological, emotional, and financial consequences from being isolated and underemployed.

Cognitive Model of Social Phobia
People with social phobia are hypersensitive to the evaluations of others. The perception of negative feedback from an "audience" (e.g., rolling eyes or yawning) triggers increased anxiety in these individuals, which in turn causes physiological anxiety symptoms such as blushing or sweating (Rapee & Heimberg, 1997). Thus, a repeating cycle consisting of perceived negative evaluations and increased anxiety is common for many of these individuals when engaged in social interactions.

Three cognitive stages have been identified when people with social phobia are involved in social interactions: (a) anticipatory processing, (b) in-situation processing, and (c) postmortem (Clark & Wells, 1995; Rowa, Antony, & Swinson, 1999). The anticipatory stage is characterized by excessive worry and apprehension about an upcoming social interaction. During the in-situation processing stage, self-talk is increased and acute attention is paid to the early warning signs of anxiety. In this stage, people with social phobia are likely to take several safety precautions, such as glancing often at the nearest exit to make sure they have an escape route if their anxiety becomes overwhelming, drinking alcohol, and avoiding eye contact. As a result, due to the excessive attention paid to internal cues during the interaction, social mishaps are likely to occur (e.g., forgetting names, inappropriate laughter or excessive talking in an effort to take their mind off their discomfort). The final stage, postmortem, is characterized by scrutiny of the past interaction. For example, Wilson (1996) discussed a case in which his client faced one of his social fears but worried incessantly afterward that he had made a fool of himself. Thus, the fears of people with social phobia can be reinforced after facing situations if proper corrective attention is not paid to their self-talk after the event.

Treatment for Social Phobia
Several treatments seem effective in helping people with social phobia. Both behavioral therapy and pharmacological treatments have been found to be salient in alleviating the symptoms of social phobia. Research related to behavioral and pharmacological treatments are described as follows.

Behavioral Treatments
Cognitive Behavioral Therapy (CBT), Cognitive Behavioral Group Therapy (CBGT; Albano, Marten, Holt, Heimberg, & Barlow, 1995; Hayward et al., 2000; Heimberg et al., 1990; Heimberg, Salzman, Holt, & Blendell, 1993), and Exposure Therapy (ET; Feske & Chambless, 1995; Turner, Beidel, & Jacob, 1994) have repeatedly demonstrated efficacy in treating social phobia. Furthermore, several studies have found that a combination of CBT and ET is superior to using either treatment alone when treating social phobia (Butler, Cullington, Mundy, Amies, & Gelder, 1984; Mattick & Peters, 1988; Mattick, Peters, & Clarke, 1989). Finally, CBGT has been found to be more effective than Educational Support Groups (ESG; Heimberg et al., 1990; Heimberg et al., 1998; Heimberg et al., 1993).

Comparing CBGT with ESG, Heimberg et al. (1990) conducted a study to examine the efficacy of CBGT designed specifically to treat social phobia versus the efficacy of an ESG (N = 49). The CBGT consisted of 4 stages: (a) teaching clients how to identify and dispute irrational thoughts; (b) role-playing fearful situations; (c) cognitive restructuring before and after role-playing; and (d) assigning homework aimed at confronting feared situations, followed by self-administered cognitive restructuring. The ESG used a combination of education and support group therapy, and session content consisted of definitions of anxiety, physiological responses, communication skills, assertiveness, and perfectionism. In the final session of the 12th week, the participants were asked to complete a simulated feared social interaction called the "behavioral test." Multiple social anxiety measures, including therapists' ratings, were taken both prior to and at the conclusion of the study as well as at the 6-month follow-up.

Results indicated that both groups' symptoms were reduced; however, the CBGT participants demonstrated more substantial improvement. In addition, the CBGT group reported significantly fewer negative thoughts after the behavioral test than did the ESG. Furthermore, the results of a subsequent study aimed at determining the durability of the CBGT with the participants in this study found that treatment gains had been maintained by the CBGT group at the 5-year follow-up (Heimberg et al., 1993). On the basis of these results, it appears that education and social support, although somewhat effective, are not as effective as CBGT. This study clearly points to the importance of helping clients recognize and change irrational thoughts and face their fears, first in controlled role-play situations, and then gradually moving to more natural interactions.

A more recent study compared CBGT, phenelzine, pill-placebo, and ESG (Heimberg et al., 1998). One hundred and thirty-three participants were divided among the four groups. After 12 weeks of therapy, results indicated that CBGT and phenelzine were more effective in reducing participants' social anxiety scores than either the pill-placebo or the ESG; however, the phenelzine group was superior to CBGT on some measures.

Two studies found the combination of CBGT and exposure therapy (ET) to be ideal in treating social phobia. In the first study, Mattick and Peters (1988) divided the 51 White male participants into two treatment groups, one group received ET (n = 26) and the other received a combination of CBGT and ET (n = 25). Participants in the ET-only group repeatedly practiced submersing themselves in fearful situations (e.g., restaurants, shopping malls) until their fear had subsided. Participants in the combined group were taught cognitive restructuring strategies to challenge their irrational thoughts, after which they began engaging in fearful situations. At the 3-month follow-up, 52% of the participants in the combination group were able to complete 100% of their predetermined "hierarchy of fearful situations" compared with only 17% of the ET-only group. Furthermore, both groups demonstrated significant decreases in their avoidance of fearful situations between pre- and posttest; however, the combination group's avoidance ratings continued to decrease, between the posttreatment and the 3-month follow-up, while the ET group's avoidance ratings increased. Thus, it appears that teaching people with social phobia CBT strategies, in addition to having them engage in fearful situations, increases the likelihood that they will continue to improve once treatment is completed.

On the basis of the previous study, and the apparent superiority of a combination of CBT and ET relative to ET alone, Mattick et al. (1989) sought to determine the difference between ET (n = 11), CBT alone (n = 11), a combination of the ET and CBT (COMB; n = 11), and a wait-list control group (WLC; n = 10) in the treatment of social phobia. All of the treatment groups improved significantly more than the WLC. Similar to what was found in the previous study, both the COMB and the ET group improved significantly between pre- and posttreatment on a behavioral achievement test; however, the COMB group showed continued improvement at the 3-month follow-up, whereas the ET group decreased. The CBT alone group made only modest gains between pre- and posttreatment; however, it continued to show significant gains at the follow-up, surpassing the ET group. The results concur with those of the previous study suggesting that a combination of both CBT and ET is ideal in treating social phobia. Based on this study, it appears that CBT is a vital component in assuring continued improvement posttreatment.

A meta-analysis conducted by Feske and Chambless (1995) found CBT and ET to be equally effective in treating social phobia; however, more exposure sessions were associated with greater symptom reductions. On the contrary, it has been suggested that exposing people with social phobia to feared situations without cognitive restructuring activities can be counterproductive. According to Wilson (1996), people with social phobia tend to scrutinize themselves negatively after social interactions; therefore, if time is not spent helping the clients identify and dispute irrational thoughts, the exposure can reinforce their negative beliefs.

In a recent review of behavioral treatments for children with anxiety disorders, CBT and CBT combined with family therapy have proven to be the most beneficial (Ollendick & King, 1998). Mendlowitz et al. (1999) examined the effects of CBGT under the following treatment conditions for children (ages 7-12) with anxiety disorders: (a) child only, (b) parent-child, and (c) parent only (N = 62). All three showed improved anxiety and depression scores; however, the parent-child group reported increased coping strategies as well.

Specifically related to the treatment of social phobia in children and adolescents is Hayward et al.'s (2000) study to determine the effectiveness of using a 16-week CBGT for treating female adolescents. The study consisted of three groups: a CBGT group (n = 12), a nontreatment social phobic group (n = 23), and a nonsocial phobic control group (n = 18) used primarily for baseline comparison. Treatment consisted of a typical CBT protocol, such as assertiveness training, social skill building, and cognitive restructuring, coupled with in vivo exposure to feared situations.

The treatment group had improved significantly more than the nontreatment group at posttreatment; however, these gains were not maintained at the 1-year follow-up. In fact, there was no significant difference in social phobia measures between the two treatment groups at the follow-up. It is interesting that there was evidence indicating that participants in the treatment group experienced less depression at the 1-year follow-up compared with the nontreatment group. Thus, the study indicated that CBGT did alleviate social phobic symptoms in the short term, but Hayward et al. (2000) suggested that booster sessions and pharmacological treatment might be needed to maintain posttreatment gains.

Barrett (1998) and Barrett, Dadds, and Rapee (1996) found that a combination of CBT and family therapy was more effective than CBT alone (participants ages 7-14 years). In fact, Barrett et al. (1996) found that 96% of the CBT-plus-family-therapy participants did not meet the criteria for social phobia at the 12-month follow-up as compared with 70% of the CBT-only group.

Family therapy comprised twelve 40-minute sessions and consisted of assisting family members to work together as a team to help the client alleviate his or her anxiety. Family members were taught how to reward courageous behavior and use "planned ignoring' to eliminate fearful behaviors. Planned ignoring involved having the parents respond empathetically to their child's first complaints about having to engage in a feared situation, but if the complaints continued, parents encouraged their child to practice the relaxation techniques taught during CBT and, finally, started to withdraw attention until the complaining subsided (Barrett et al., 1996). In addition, parents were taught how to manage their own anxiety in stressful situations. Finally, in an effort to prevent future problems, parents were taught communication and problem-solving skills and were encouraged to conduct daily discussions with their child to diffuse stressors before they began.

Implications for Counseling
First, because many people with social phobia never seek treatment, it is imperative for counselors to increase the general public's awareness of this disorder. In schools, counselors should attempt to educate teachers and parents about the symptoms of social phobia and its treatment options. In addition, classroom guidance lessons could be designed to teach students coping skills for managing anxiety (e.g., relaxation techniques, positive affirmations). In the community, screenings for social phobia, much like what is done for other mental health disorders during mental health awareness week, could be conducted in local libraries and other agencies to provide outreach to this underserved population.

A substantial obstacle to receiving treatment for many people with social phobia is the discomfort they feel making contact with other individuals (Schneier et al., 1992). All efforts should be made by counselors to create an inviting and nonthreatening atmosphere. Counselors should make clients with social phobia aware that they can leave the office for a "breather" at any time during the session, if necessary, or they can lie down if their symptoms become intense. In addition, a client with social phobia is likely to experience anxiety during a session, causing him or her to pay more attention to internal feedback instead of being focused on the counselor; thus, it is important for counselors to summarize the discussed material often and to encourage their clients to write down important information and insights gleaned so they can be reviewed outside of session (Butler & Wells, 1995). Finally, traditional counselor behaviors, such as direct eye contact and sitting close to the client, especially in the first sessions, will probably cause people with social phobia much discomfort. Therefore, when working with people with social phobia, a traditional psychoanalytic approach of having the client face away from the counselor may be warranted. In fact, a client's willingness to make eye contact and face the counselor in subsequent sessions could be used as a measure of treatment success.

Second, anxiety can be a symptom of many medical conditions. Some of these conditions include diabetes, heart arrhythmia, asthma, thyroid conditions, mitral valve prolapse, hypoglycemia, pregnancy, anemia, medication withdrawal, and the effects of caffeine (Wilson, 1996). Therefore, counselors should encourage their clients to have a thorough medical examination before receiving treatment.

Third, helping clients change their irrational beliefs through cognitive restructuring and exposure to feared situations through role-play and then in-vivo exposure appears to be the behavioral treatment of choice for adults. Common components of effective CBT include educating clients about the nature of the disorder, teaching social skills, assertiveness training, cognitive restructuring, role-play, and the analysis of in-vivo exposure. One of the main components of CBT and CBGT is to help clients learn to challenge their negative self-defeating beliefs. Wilson (1996) and Masia and Schneier (1999) encouraged clients to become accustomed to using the following statements and questions when involved in feared situations: "It's OK to be nervous" "What is the worst that could happen and is that so bad?" "Are there other ways of viewing this situation?" "My speech does not have to be perfect."

Fourth, counselors should prepare clients to face feared situations. Oftentimes, this is done initially in role-play situations under the guidance of the counselor so the event can be processed immediately afterward. Once successful role-plays have been enacted, the goal is then to help clients practice during real-life situations. These assignments can be given as homework to be carried out between sessions. For example, clients may be asked to initiate three conversations with people they do not know during the week and report back in the next session.

Exposure therapy has been found to be most effective under the following conditions: (a) Clients must remain in the feared situation until they notice a significant reduction (i.e., at least 50%) of their anxiety symptoms (Butler, 1985); (b) they must refrain from using safety behaviors (e.g., checking for exits and avoiding eye contact; Wells et al., 1995); and (c) they must engage in anxiety-provoking situations often to best eliminate their fear. It is common for people with social phobia to scrutinize themselves after social interactions; therefore, if they leave an in-vivo exposure at the height of their anxiety, this will only serve to reinforce their fear. In addition, if their symptoms become so intense that they must leave a fearful situation, it is important for them to challenge the onslaught of negative self-talk, which can reduce their willingness to face the situation in the future.

Fifth, counselors should encourage their clients with social phobia to invite close family members and significant others to participate in therapy. Although couples or family counseling has not been examined specifically for adults with social phobia, evidence suggests that couples counseling is effective when working with people who have other types of anxiety disorders (Barlow, O'Brien, & Last, 1984; Cerny, Barlow, Craske, & Himadi, 1987). Including significant others in therapy reduces the chance that the significant other will ignore the problem of the partner who has social phobia or will push him or her excessively into uncomfortable situations (Barlow et al., 1984). In addition, significant others' lifestyles will be affected by the problems experienced by their partners who have social phobia. Anecdotal evidence suggests that those who live with people with anxiety disorders commonly experience feelings of anger, resentment, and confusion. Thus, efforts should be made to educate and support significant others.

It is clear that combining CBGT and family therapy is effective when working with children and adolescents with social phobia. Counselors should provide parents and guardians with education and support to help their children develop coping skills. In addition, because of the strong genetic link between parent and child anxiety, the assessment and treatment of parents' anxiety is important as well.

Sixth, it is important for counselors to become familiar with the medicines commonly used to treat social phobia and their side effects. As mentioned earlier, the SSRIs are typically the first line of treatment. However, these medicines can take up to 4 weeks to take effect, and several clinical trials indicated that only 50% to 60% of the participants improved, leaving another 40% to 50% that were not helped. Common side effects of SSRIs include headache, abdominal discomfort, nausea, and insomnia (Birmaher et al., 1994; The Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2001).

Finally, two sources are recommended for those who seek additional information about social phobia. On the Internet, the Social Anxiety Institute (www.socialanxietyinstitute.org) is a good site to learn more about social phobia, and those who are interested can register to receive a confidential newsletter that is edited by mental health professionals and contains information about current treatment options and allows members to share their coping strategies. An excellent source for counselors is the book Social Phobia: Diagnosis, Assessment, and Treatment edited by Heimberg, Liebowitz, Hope, and Schneier (1995). This book contains chapters written by the foremost researchers of social phobia.

Social phobia is a serious condition that can be disabling. It is often comorbid with other disorders, causing a significant deterioration in the quality of life of those who have this condition. Fortunately, both behavioral and pharmacological treatments have proven effective in treating this condition; nevertheless, further research is needed to examine the efficacy of using a combination of pharmacology with CBGT. Furthermore, longitudinal studies are needed to determine if the treatment of children and adolescents with social phobia produces lasting effects or if it thwarts some of the more severe symptoms that they may experience later in their lives. At the very least, based on the favorable treatment results, it is important for counselors who work with children and adolescents to identify and treat those who exhibit symptoms of social phobia. Finally, counselors need to increase the general publics' awareness of this disorder and to adjust their counseling styles to best meet the needs of those who have social phobia.
- Curtis, Russell C., Kimball, Amy, Stroup, Erin L.; Understanding and Treating Social Phobia; Journal of Counseling and Development; Winter 2004; Vol. 82, Issue 1.

Personal Reflection Exercise #4
The preceding section contained information about the treatment of social phobia.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
What are two reasons significant others should be encouraged to attend therapy with their socially phobic partner? Record the letter of the correct answer the CEU Answer Booklet.

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