Behavioural – Avoidance of Colleague.
Although this model can be criticised for being too simplistic and failing to take social factors into account that can affect all its component parts, it does illustrate how SP can be disabling for the client as it reveals that the emotional distress and avoidant behaviour (C) is a consequence of the negative inferences and evaluations (B), and not, as the client mistakenly believes, a consequence of the activating event (A).
There may be many innocent reasons as to why the colleague ignored the client, but it is how the client not only interpreted the colleague’s action negatively, but also inferred a negative meaning and subsequently a negative evaluation, as it is certainly not catastrophic if someone does not like you.
During assessment, the CB therapist will identify the A’s, B’s, and C’s by focusing on a specific emotional episode and following this procedure:
1) Assess the C
2) Assess the A
3) Connect the A and C
4) Assess B
5) Connect B to C
Both (A) and (C) are assessed before (B) and 2 or 3 of these assessments are conducted as there are often several emotional episodes that have an underlying irrational belief (B) in common.
It is this identification of (B) that facilitates the next stage of formulation.
A CB formulation makes an assertion that the client has one or more irrational beliefs underlying several specific episodes. CB formulations integrate information gathered during assessment and provide a working hypothesis for how the client’s SP developed, how the SP is being maintained by the client and how it might be resolved. Any formulation made by the CB therapist must be based on the client’s stated problems and be accepted by the client as a working formulation which then goes on to form the basis for CB intervention.
Examples of case formulations include the Three Systems Approach (Rachman & Hodgson, 1974), illustrated diagrammatically below, which attempts to understand emotional issues in behavioural, cognitive and physiological terms.
However, this model does not take into account any environmental issues that may have precipitated the emotional distress. This failing was addressed by Greenberg and Padesky, (1995) in the Five Aspect Model, illustrated diagrammatically below.
In this model, all aspects are experienced within the environment. An individual’s ethnicity, socio-economic status, education level or upbringing can all be considered as environmental aspects of the problem.
Using a fictitious client example, James has been referred by his GP for counselling for SP. His CB therapist has conducted 3 ABC assessments, the first of which revealed that James is anxious about a job interview (A) and thinks that people will judge him as stupid (B).
James’s second assessment revealed his worry about blushing when dealing with people in authority (A) and that this means that he is physically abnormal (B). His third assessment revealed his nausea (A) before delivering a best man speech where everyone would laugh at him (B).
A general formulation here would be that James’s SP results from his tendency to misinterpret the facial expressions and reactions of others and his constant negative evaluation of himself in the social situation of work.
It is important that the client genuinely understands the formulation. Irwin et al (1985) found that only 25% of patients genuinely understood the benefits and side effects of their treatment when questioned specifically. This means 75% did not, and without this understanding, the client will not attribute any changes to their own efforts.
Once the therapist is satisfied that the client genuinely understands the formulations, then the 4 steps of intervention can begin. Firstly, the therapist and the client must agree on specific formulations to work on and secondly, using these formulations as a guide, they must together select specific goals that the client wishes to work on.
Step 3 is the selection by the client, and agreed on by the therapist, of specific tasks that will help achieve the specific goals. These tasks may include the keeping of a diary of events, behaviour and emotions. Key elements of CBT treatments include Exposure, in which a client enters and remains in a feared situation despite distress, either in vivo or in vetro, beginning with situations that the client has ranked as moderately fear-provoking and moving up gradually to more highly feared situations. The use of Exposure techniques is based on the assumption that the client must fully experience the feared situation in order for change in emotional and behavioural symptoms to occur (Foa & Kozak, 1986).
Relaxation techniques are also used in order to help the client deal with the physiological symptoms of SP. Progressive muscle relaxation (PMR) techniques are taught to the client so that they can practice using the techniques during everyday activities and then be able to use them when in a fear provoking situation (Ost, 1987).
A final key element in the CBT treatment arsenal is Cognitive Restructuring (CR). This is based on the assumption that it is the client’s irrational thoughts and beliefs that perpetuate the SP and not the actual situation (Beck & Emery, 1985).CR is often used in combination with Exposure to challenge the client’s irrational thoughts and beliefs rather than simply a process of teaching the client to ignore SP provoking stimuli.
Finally, step 4 is the agreement of boundary conditions where the therapist and client agree by negotiation the number, frequency and duration of sessions, the agendas of those sessions, role relationship and locus of responsibility.
Strengths and limitations of CBT
CBT is a collaborative treatment, with the therapist as an ‘expert in friend’s clothing’ rather than an aloof and removed ‘expert in doctor’s uniform’. It helps the client to develop new skills for their use in future situations, and its brevity and time-limited aspect makes it attractive for cost-conscious primary care trusts here in the UK.
CBT’s focus on the issues in the here and now help to break maladaptive thinking and behavioural patterns that maintain the client’s distress levels. This in turn may help past issues from a current viewpoint, as the new skills develop to cope with one situation, they can also be applied to other situations by the client to effectively ‘heal’ themselves.
CBT’s structure and specificity in relation to goals and tasks make it very easy to evaluate and research and also gives the client positive reinforcement by being enabled to achieve realistic goals. Few studies have compared CBT with other psychotherapies in the treatment of SP, however, Cottraux et al. (2000) found that CBT was superior to supportive therapy. Treatment effects for CBT were sustained at 36 and 60 week follow-ups, although the long-term effects of supportive therapy were not assessed.
CBT also has its limitations. Efficacy rates depend on the client’s expectations of success, their willingness to complete the behavioural tasks and their ability to confront uncomfortable thoughts (Rosenbaum & Horowitz, 1983; Marmar, Weiss & Gaston, 1989).
Psychological therapies in general are increasingly becoming an integral part of government planning in mental health care with CBT increasingly being viewed by government as the first choice of treatment for many psychological problems (Clark et al, 2009) however, CBT’s apparent superiority may be undeserved.
The NIMH study, now 20 years old, was the largest in the world and it found CBT performed poorly in comparison to interpersonal therapy and drug therapy (Elkin, 1994, pp. 114-142). There is also the question of CBT’s clinical relevance as opposed to its ability to produce change under lab conditions. CBT may do well in university based clinical trials with participants recruited from adverts but in the real world of clinical practice, not so well. Leff et al (2000) found that in the London Depression Trial, CBT was discontinued early due to poor compliance from clinically typical patients.
CBT does not address the biological issues that may cause SP, as mentioned earlier in Blair et al (2008) and their findings regarding the amygdala’s role in causing SP, neither does it take into account the issue of co-morbidity, especially with Axis II disorders that could seriously disrupt CBT treatment. Alnaes and Torgersen (1988) found that patients with borderline personality disorder are at heightened risk for developing an anxiety disorder while Oldham et al (1995) found significant levels of comorbidity of anxiety disorders with borderline, avoidant, and dependent personality disorders. Developmental psychologists argue that SP can result from attachment problems in early childhood. Longitudinal analyses (Brumariu & Kerns, 2008) showed that lower attachment security and higher ambivalent attachment were most consistently correlated with higher social anxiety levels.
Alternatives to CBT include hypnotherapy (Kirsch et al, 1995; Vickers & Zollman, 2001), which has shown promising results when combined with CBT. Antidepressants were initially developed to treat depression, but they are now also used to treat anxiety disorders. SSRIs such as fluoxetine (Prozac) and sertraline (Zoloft) are commonly prescribed by starting at low doses and then increased in dosage levels over time for panic disorder and social phobia (Hauser, 2006). Neural Linguistic Programming (NLP) has also shown to be effective as a ‘fast phobia cure’. Konefal & Duncan (1998) provides evidence of significant reductions in SP using the Liebowitz Social Phobia Scale after NLP training.
In conclusion, while CBT may have its limitations, and depend largely on the co-operation of the client, the same can be said for any psychotherapy as the outcome appears to be considerably enhanced when the client and therapist are actively involved in a cooperative relationship (Tryon & Winograd, 2011). It is of note that Horvath et al (2011) found that the effect size of the link between alliance and psychotherapy outcomes was 0.275, and that this statistically significant effect accounts for about 7.5% of the variance in outcomes, showing that the alliance-outcome relationship is one of the strongest predictors of treatment success that any research has been able to document thus far.
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