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Treating social anxiety disorder: video (and still) feedback (6th post)

Back last autumn I wrote five detailed blog posts about CBT treatment of social anxiety disorder and also a further post giving access to a series of assessment & monitoring questionnaires - "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: introduction (1st post)""David Clark's treatment for social anxiety: assessment (2nd post)""Treatment for social anxiety: personal aims (3rd post)", "Treatment for social anxiety: avoidance & safety behaviours (4th post)""Treatment for social anxiety: more on avoidance, social skills and compassion (5th post)" and "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder". You can get even more on assessment & monitoring by going to this website's "Good knowledge" page - "Social anxiety information & assessment" - and even more on social anxiety generally by retrieving other relevant blog posts through clicking on "Social anxiety" in the tag cloud.

At the workshop I attended with David Clark, he listed "five innovations" involved in his treatment of social anxiety disorder - 1.)  self-focused attention & safety behaviours experiments.  2.)  video (and still) feedback.  3.)  attention training.  4.)  behavioural experiments.  5.)  then v's now discrimination training & rescripting early socially traumatic memories.  He commented that when treating panic disorder one can typically come at it in any old order; the treatment 'wrecking ball' gradually crumbling the construction of unhelpful catastrophic fears.  In contrast, for social anxiety disorder, David feels that the sequence is important with treatment components 1.) & 2.) needing to precede components 3.) & 4.).  The first two components help people to realise that the ways that they have been trying to manage their social anxiety are themselves problematic ... that their attempted solutions are typically aggravating their difficulties.  As a throwaway line, he described social anxiety disorder as involving "a grand opera of safety behaviours".  Treatment components 3.) & 4.) are then only brought in after the initial 'softening up' of unhelpful beliefs achieved by using approaches 1.) & 2.).

In the fourth post in this sequence on social anxiety disorder - "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours" - I discussed identification of safety behaviours in considerable detail.  The subsequent "self-focused attention & safety behaviour experiment" involves in-session increase & decrease of these identified self-defeating coping strategies.  This is very well described in the "Social anxiety" chapter by Gillian Butler & Ann Hackmann in the 2004 book "Oxford guide to behavioural experiments in cognitive therapy".  David showed a series of slides describing this procedure.  He recommended choosing a mid-level social challenge - for example one that is likely to produce approximately 50 units of distress on a simple 0 to 100 scale assessing distress usually caused by a variety of social interactions.  A common example would be a 5 minutes or so conversation with a stooge/stranger (played typically by a colleague or employee of the therapist).  Other options include standing up and giving a short talk, holding a glass of water while chatting, and a variety of other personalised challenges.

The "Safety behaviours video experiment" form (downloadable in Word doc or PDF format) helps therapist & client clarify what safety behaviours are to be emphasised during the experiment and also what is going to be assessed - for example how distressed the client feels during the role play, and also crucially how they feel they "come across".  This might involve assessments of social competence (stupidity, fluency, etc) and/or assessments of anxiety signs (facial colour, sweating, trembling, voice shaking, etc).  It seems important that the client makes explicit demonstrated predictions about just how bad they believe their anxiety signs are going to be, otherwise their biased judgements may just seize on what they see in the video of their subsequent behaviour and say something like "I told you so ... look how badly I come across."  If they have been asked to predict & demonstrate the extent of their observable anxiety before the role play is videoed, then there is a more objective way of demonstrating how their fears have been exaggerated.  So, for example, they could be asked to demonstrate how they feel their trembling or shaky voice or other anxiety signs will actually come across on the video.  For assessment of blushing one can use paint colour charts which can be ordered for free on the internet.  All this allows a more memorable & definite post-experiment checking back on the accuracy of their catastrophic expectations. Remember that a key component of CBT treatment for social anxiety disorder lies in demonstrating that assessing others' judgements from one's own internal anxiety experience is comparing apples with oranges ... others' judgements & one's own inner experience just don't match up particularly closely.  

David also made the puzzling comment that "A big trap is the therapist believing what they see."  I think the point he was making was that the client may well look pretty anxious to the therapist (and to the assistant/stooge as well) when performing the videoed behavioural experiment.  However the client is very likely to estimate that they looked much more anxious than they came across ... so the therapist observes say 30 or 40 degrees of anxiety on a 0 - 100 scale, but the client estimates that they came across at level 70 or 80.  In fact, research suggests that the higher the degree of anxiety, the greater the discrepancy between how someone looks to an outsider and how they feel inside.  So if the therapist sees a fair amount of visible anxiety, it's a good bet that the client is experiencing (and will estimate) a much higher observable anxiety score than the therapist (or stooge) will give them. 

For more on this very interesting use of video experiments in the highly effective CBT treatment of social anxiety disorder, see the next post in this sequence "Treating social anxiety disorder: video (and still) feedback (7th post)".

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