10 The Treatments of Social Phobia: Their Nature and Effects If ‘‘epidemiological’’ studies are to be believed, estimated rates of prevalence of social phobia at the present are generally lower than those over the ‘‘lifetime.’’ Natural social processes (e.g meeting an enterprising admirer, a sympathetic but demanding teacher) leading to remission would account for the difference Little evidence of such benign processes can be seen however in the lives of patients seeking help, perhaps because these are for the most part little capable of taking advantage of naturally occurring social opportunities Social phobia typically crystallizes as a pattern in the face of the increasingly insistent social and interpersonal demands of adulthood made on adolescents, and remains among the most chronic problems seen in the clinic (see chapter 5) Help is often sought long after the onset of problems What of proven value can be offered such patients? An attempt at the valuation of treatments of social phobia requires establishing boundaries as to what claims to consider and which to dismiss outright or ignore What are the possibilities? One end of a continuum of strictness might be defined as an indulgent approach relying on the self-valuation of the proponents of various treatments The other end might be designated as a discerning approach demanding relatively high quality of evidence Immoderately, I shall opt for the latter for it seems to me that the most meaningful answer will arise from the careful selection of the best available studies, methodologically speaking This provides as much guarantee as can be had for the relative soundness of the results, but not necessarily of the conclusions drawn from them These must be judged on their own merits Studies included in this review had to satisfy the following requirements: The sample had to admit only social phobic participants; in the interest of clarity, mixed samples were excluded As the onset of social phobia is typically in late adolescence, all studies concern adult patients 289 290 What Helps Social Phobic Individuals? Clinical status had to be determined by publicly recognized defining criteria e.g DSM-IV The assessment battery had to use multiple measures of outcome; given that the psychometric characteristics of individual measures often leave much to be desired, a convergence of outcome of all or most measures enhances confidence in the validity of the results The study design had to involve more than one experimental condition (and therefore random assignment of patients to them) Consequently, this survey was limited to ‘‘controlled’’ studies that contrast the experimental treatment with either a well-established treatment of known outcome or an experimental condition that simulates a treatment without offering its substance (e.g ‘‘placebo’’) Placebo (from the Latin placere, literally, I shall be pleasing) controls are desirable because dealings between individuals recognized as healers and cure-seeking sufferers are known to stimulate self-healing and might therefore constitute a confound Such simulation of treatment, to have an effect, must be culturally sanctioned in the terms of reference of the patient (see Moerman, 2002) Shamanic rituals aiming to appease offended spirits (incantations, amulets, potions) for example, would be meaningless to the western patient This, on the other hand, responds powerfully to medical authority and hopefully to its healing rituals (establishing diagnosis, prescribing pills, performing surgery), embedded in a shared outlook (‘‘science’’), construing the living organism as a machine and inadequate functioning as its breakdown (in this case, of the brain or the mind) Three potential strands of outcome were considered: Reduction in subjective distress in and avoidance of anxiety-evoking situations; this was taken as the main measure of improvement owing to its adoption as such by most studies It is the natural upshot of the commonly held view that social phobia is a ‘‘disorder’’ of social anxiety This aspect of outcome will be summarized throughout Improvement in social functioning (i.e the manner in which the patient participates in social life, assumes roles, and fits in; see Beattie & Stevenson, 1984) Relatively few studies measured this effect of treatment although impaired social functioning is at the heart of social phobia and one of the defining criteria in DSM-IV Consequently, it will be summarized only when available The Treatments 291 Improvement in clinical status (i.e remission) As the best result possible it sets an absolute standard Improvements in social anxiety and social functioning, by contrast, are relative to pretreatment levels Although ostensibly ‘‘significant’’ by statistical standards, such gains might be modest from the point of view of the difference they make to patients’ lives Rates of remission will be reported only when available Current Contents, Medline, and PsychInfo electronic databases were systematically searched in order to increase the likelihood of including all relevant publications The selected studies broadly fell into categories of treatments: the purely psychological, the purely pharmacological, and the combination or comparison of both Psychological Treatments Two broad strategies have emerged in the psychological treatment of social phobia: anxiety reduction and improvement in social functioning Anxiety Reduction Exposure and cognitive restructuring are the main tactics used within the broad anxiety-reduction strategy In principle, exposure is the therapeutic application of the welldemonstrated fact (Marks, 1987, pp 457
494) that repeated and prolonged exposure to the anxiety-evoking social setting results in significant reduction in anxiety It is arguably the methodical application of the principle of habituation, documented in various studies (e.g Mauss, Wilhelm, & Gross, 2003) Exposure is particularly useful when a strong tendency to avoid is manifest Practically, a graded hierarchy of increasingly difficult situations might be devised Starting at the lower end of the hierarchy, the patient will be induced to face up to the feared situation (perhaps simulated) in the clinic and remain in it until distress subsides Later on (or immediately) exposure will be extended to real-life situations among others by means of self-exposure assignments to be performed in-between sessions In theory, cognitive restructuring (a generic term for different models of cognitive modification) rests on the assumption that erroneous thinking, fed by mistaken beliefs, generates social anxiety The clinician practicing this sort of therapy first identifies presumed systematic errors in thinking (i.e irrational inference drawing; e.g exaggerating, ignoring 292 What Helps Social Phobic Individuals? counter-evidence) as inferred from the narrative of the patient Second, in addition to these, putative underlying organizing broad beliefs (‘‘schemas’’) expressing a whole outlook (e.g being above reproach guarantees safety), similarly inferred, are challenged Between sessions, patients are sent to confront anxiety-evoking encounters and asked to identify their anxiety-generating thoughts as they arise and rebut them using methods taught during sessions Although cognitive restructuring might be used as a technique in an otherwise behavioral treatment, it is typically the organizing principle of a therapy relying on (exposure-like) graduated social tasks, construed as experiments in putting patients’ assumptions to a test Such a regimen is known as cognitive behavior therapy (CBT) The evaluation of anxiety reduction by means of either exposure or cognitive restructuring as a general orientation to the treatment of social phobia has generated most research It is the natural outgrowth of the construal of social phobia as a ‘‘disorder’’ of anxiety Anxiety in turn is conceived of intra-personally (i.e as an enduring quality of the individual generated from within; see chapter for a detailed discussion of the term) In addition to this primary effort, a good proportion of the research attempted to gauge the relative effects of exposure and cognitive restructuring The backdrop to this line of research is a theoretical clash between two rival outlooks: behaviorism and cognitivism The design and outcome of the studies assessing exposure and cognitive restructuring are displayed in Table 10.1 Overall exposure and CBT are of value for both single- (usually public-speaking) and multi-situation (generalized) social phobia, yielding clinical improvement in distress and avoidance either in a group or individual format Statistically significant improvements from pretreatment levels are achieved in between to 12 sessions with up to 15% dropping out These gains not obtain in control conditions, and tend to be maintained at 6
18 month follow-up, with one report of gains maintained till 5
6 years follow-up Although it is widely assumed that reduced (presumably more manageable) levels of social anxiety lead automatically to meaningfully improved social functioning, there is little evidence to support this Better-focused research is needed to clarify this important point Conversely, the addition of social skills training to CBT enhanced its effects in terms of anxiety reduction and improved social functioning (Herbert, Gaudiano, Rheingold, Myers, Dalrymple, & Nolan, 2005) Treatment conditions Hope et al (1995a) EXP (G); n ẳ 11 EXP ỵ CR (G); n ẳ 18 WL; n ¼ 11 12 sessions  h Newman et al sessions  h EXP (G); n ¼ 18 (1994) WL; n ¼ 18 Scholing & sessions  1h Emmelkamp (4 weeks) EXP (I); n ¼ 10 (1993a) CR (I); n ẳ 10 EXP ỵ CR (I); n ẳ 10 WL Exposure alone vs waiting list Mattick et al sessions  h CR (G); n ¼ 11 (1989) EXP (G); n ¼ 11 EXP ỵ CR (G); n ẳ 11 WL; n ¼ 10 Study 1¼243 _ 1¼2¼3¼4 (all improved) (1 ¼ ¼ 3) 4 not improved Social Avoidance Outcome _ Social Functioning 2, _ 1¼2 _ (no improvement) _ (1 ¼ ¼ 3) 4 not improved Subjective Distress Table 10.1 Comparative outcome of psychological approaches
anxiety reduction Improvement stable at months (1 ¼ 2) _ Improvement stable at months for other conditions Exposure improved only at follow-up Follow-up 0% 1¼243 70% 36% Responders Exposure superior on some measures Comments Treatment conditions Social Avoidance Outcome sessions  2.5 h EXP (G); n ẳ 24 EXP ỵ CR (G); n ¼ 24 WL; n ¼ 23 _ Scholing & sessions  h Emmelkamp (4 weeks) EXP (I); n ¼ 10 (1993a) CR (I); n ẳ 10 EXP ỵ CR (I); n ẳ 10 WL 1¼2¼3¼4 (all improved) Cognitive restructuring alone vs waiting list Mattick et al sessions  h CR (G); n ¼ 11 (1 ¼ ¼ 3) 4 (1989) EXP (G); n ¼ 11 not improved EXP ỵ CR (G); n ẳ 11 WL; n ¼ 10 Salaberria & Echeburua (1998) Mersch (1995) 14 sessions  h EXP (I) (1 ¼ 2) CR H SST H EXP (I) ỵ 2; n ẳ 17 WL; n ¼ 17 Study Table 10.1 (cont.) _ (1 ¼ ¼ 3) 4 not improved (1 ¼ 2) (1 ¼ 2) Subjective Distress _ _ _ (1 ¼ 2) Social Functioning _ _ _ _ Follow-up Comments Emmelkamp sessions  2.5 h et al (1985) EXP (G) CR (selfinstruction variant) (G) CR (rationalemotive variant) (G) n ¼ 38 Exposure vs cognitive restructuring 1¼2¼3 not improved 1¼2¼3 (all improved) _ _ Improvement stable at Patients were on various month medications Exposure showed further improvement on the avoidance and anxiety measures 50% 241 Significant results obtained only on one of six measures Responders 14% Further significant reductions for the individual modality 1¼243 _ _ Remitters 14% _ _ _ Improvement stable at months 15 weeks CR (G: 15  h); n ¼ 26 CR (I: 15  h); n ¼ 24 WL; n ¼ 21 ¼ (?) 142 Stangier et al (2003) 142 7% 1¼2 sessions  1.5 h CR (I); n ¼ 32 NSP (control) (I); n ¼ 28 Cottraux et al weeks 142 CR (I) (8  h); (2000) n ¼ 31 NSP (control) (I) (3  30 min); n ¼ 32 Taylor et al (1997) sessions  h CR (G); n ¼ 11 EXP (G); n ẳ 11 EXP ỵ CR (G); n ¼ 11 WL; n ¼ 10 Mattick et al (1989) 1¼2¼3¼4 (all improved) (1 ¼ ¼ 3) 4 not improved Social Avoidance Outcome Mattick & Peters (1988) sessions  h EXP (G); n ẳ 26 EXP ỵ CR (G); n ¼ 25 ¼ (both improved) Exposure vs exposure combined with other ingredients Butler et al sessions  h EXP ỵ AM (I); 1ẳ243 (1984) n ẳ 15 EXP ỵ NSP (control) (I); n ¼ 15 WL; n ¼ 15 Scholing & sessions  h Emmelkamp (4 weeks) EXP (I); n ¼ 10 (1993a) CR (I); n ¼ 10 EXP ỵ CR (I); n ẳ 10 WL Treatment conditions Study Table 10.1 (cont.) ¼ (both improved) 142¼3 _ (1 ¼ ¼ 3) 4 not improved Subjective Distress _ 1¼2¼3 not improved _ _ Social Functioning Comments Improvement stable at months The combined group was superior to exposure alone on some measures of avoidance At months, a Although anxiety significant difference management made appeared on the some contribution to avoidance measure outcome, it was not (1 2) meaningful Exposure improved only at follow-up Improvement stable at months for other conditions Follow-up sessions  h CR (G); n ¼ 11 EXP (G); n ¼ 11 EXP ỵ CR (G); n ẳ 11 WL; n ¼ 10 12 sessions  h EXP (G); n ẳ 11 EXP ỵ CR (G); n ¼ 18 WL; n ¼ 11 Mersch (1995) 14 sessions  h EXP (I) CR H SST H EXP (I) ỵ 2; n ẳ 17 WL; n ¼ 17 Hope et al (1995a) Scholing & sessions  h Emmelkamp (4 weeks) EXP (I); n ¼ 10 (1993a) CR (I); n ẳ 10 EXP ỵ CR (I); n ẳ 10 WL Mattick et al (1989) (1 ¼ 2) 1¼243 1¼2¼3¼4 (all improved) (1 ¼ ¼ 3) 4 not improved (1 ¼ 2) 4 2, _ (1 ¼ ¼ 3) 4 not improved (1 ¼ 2) _ _ _ Improvement stable at 18 months (1 ¼ 2) Further improvement on the avoidance measure from months Improvement stable at months (1 ¼ 2) _ Exposure improved only at follow-up Improvement stable at months for other conditions Avoidant personality disorder patients responded equally well to all treatments, but functioned less well at months follow-up Responders 70% 36% 0% 1¼243 sessions  2.5 h EXP (G); n ¼ 24 EXP ỵ CR (G); n ẳ 24 WL; n ¼ 23 Salaberria & Echeburua (1998) _ Social Avoidance Outcome (1 ¼ 2) Subjective Distress _ Social Functioning Improvement stable at 12 months (1 ¼ 2) Further improvement for both groups between post-test and months follow-up Follow-up The distribution of a self-help manual has not contributed to outcome Remitters Post-test 44% 44%: (1 ¼ 2) 12 months 66% 61%: (1 ¼ 2) Comments Note: AM: Anxiety management; CR: Cognitive restructuring; EXP: Exposure in vivo; G: Group modality; I: Individual modality; NSP: Non specific psychotherapy; SST: Social skills training; WL: Waiting list; ỵ: combined with; H: followed by; Highlighted areas ¼ treatments compared Treatment conditions Study Table 10.1 (cont.) ... inadequacy on the part of the patients foreseeing failure in achieving their social aims The second approach by contrast, de-emphasizes the formal/structural aspects of the proper performance of social. .. ways of dealing with their real-life social circumstances, and to use them in situations very much a part of their daily lives The emphasis in therapy is on finding ways of behaving that will... constitute social phobia and turning it around Positively stated, that means enhancing the participation of the individual in the social life of the community of which he or she is a member in the pursuit