Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: more on avoidance & safety behaviours (5th post)Originally added on Mon, 02/12/2013 - 06:24
Last updated on Fri, 06/12/2013 - 05:29
In a recent blog post - "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours (4th post)" - I discussed identification of avoidance & safety behaviours using questionnaires like David Clark's "Behaviours questionnaire" and Ronald Rapee's "Subtle avoidance frequency examination (SAFE)". I mentioned too that David Moscovitch's "Negative self-portrayal scale (NSPS)" could help alert us to aspects of the self that a social anxiety sufferer might be particularly invested in trying to keep "hidden" from anticipated judgement by others. Once one has a sense of what kinds of fears and concerns are particularly troubling a client, then one can ask avoidance & safety behaviour eliciting questions like "Are there things you do or avoid doing to try to keep yourself safe in this area ... or to keep this self-judged aspect of yourself from being observed by others?" As is often the case, going into a recent illustrative episode of distress in considerable detail may well throw up a series of external & internal avoidance and safety seeking practices that could be targets for therapy. Using the "Social anxiety flow chart" may be particularly useful here. Giving clients "detective" homework to look for and note down safety behaviours may well also be useful. Simple measures like the "Work & social adjustment scale (W&SAS)" and the "Pittsburgh enjoyable activities test (PEAT)" can also help.
I find it brings these issues to life for myself when I consider my own long-term patterns. When I was a teenager, I was occasionally bothered by blushing. In many ways I was a pretty confident, extrovert kid but I hated being seen to blush. In classic Moscovitch "Negative self-portrayal" style, this was an aspect of myself that I was ashamed of and didn't want others to observe and (I assumed) judge negatively. When I try to remember how I felt & acted back then and how this pattern has evolved since, it really helps me get a potentially very useful insider view of social anxiety disorder. Paradoxically, although I can still sometimes be "ambushed" by episodes of blushing & sweating, I actually score considerably less socially anxious than typical general population averages on measures like the "Negative self-portrayal scale" and the "Liebowitz social anxiety scale". This fits. I score high on the personality trait of extraversion and actually seek out opportunities to give parties for friends or lecture on subjects that seem important to me. Despite this, when I go looking for safety & avoidance behaviours, fascinatingly I find long-term patterns that I no longer even particularly think of as ways of avoiding blushing or sweating excessively. These include preferences for cooler clothing & cooler rooms. Additionally the private boys' boarding school I was sent to as a teenager was, in many ways, a pretty unpleasant, snobby environment. At a parents' visiting day, I remember boys leaning out of an upstairs school window and quietly ridiculing anyone who didn't arrive in expensive cars & expensive clothes. My dear parents weren't of this "upper class" type and certainly didn't drive a particularly smart car. I remember feeling ashamed ... and now, of course, a bit ashamed that I was ashamed! It surfaces very rarely, but I notice echoes from those experiences in tending to avoid very smart restaurants, "top" hotels or other similar environments. It's a little complex because I actually don't like these places anyway for a series of ethical & political reasons ... but I suspect that such situations could still trigger ex-school teenage feelings of not "making the grade". Well this could lead to some interesting safety behaviour challenges for me ... possibly going to the smartest restaurant in town while insisting on not taking off a very shabby but extremely warm coat!
More broadly, I do think that questionnaires like the "Negative self-portrayal scale (NSPS)" (and the "Subtle avoidance frequency examination (SAFE)") along with associated discussion can ferret out safety & avoidance behaviours that could be maintaining an underlying sense that certain situations aren't "safe". David Clark's model of social anxiety disorder hypothesises that "In-situation safety seeking behaviours and self-focused attention prevent disconfirmation of social phobics' negative beliefs and maintain social phobia" and also that "In-situation safety behaviours and self-focused attention can contaminate social interactions by making social phobics less appealing to others." As an aside here, Clark's treatment of social anxiety doesn't typically focus on teaching social phobics better interaction skills ... it's usually just assumed that as safety behaviours reduce then the unobstructed social skills that emerge need no improvement. This isn't necessarily so ... or it isn't necessarily the case that it's always therapeutically "enough" just to encourage dropping safety behaviours. Sometimes encouraging more externally-focused action may add usefully to an approach mainly looks at reducing forms of avoidance. As is illustrated in this year's study by Voncken et al - "Socially anxious individuals get a second chance after being disliked at first sight: The role of self-disclosure in the development of likeability in sequential social contact" - people suffering from social anxiety may project "coldness" or "standoffishness" through a whole series of mechanisms from body posture, facial expression, lack of eye contact & clothing to vocal tone, level of self-disclosure, warmth & empathy. The paper's abstract reads "Socially anxious individuals (SAs) not only fear social rejection, accumulating studies show that SAs are indeed judged as less likeable after social interaction with others. This study investigates if SAs already make a more negative impression on others in the very first seconds of contact. The study further investigates the development of likeability and the role of self-disclosure herein in two sequential social interactions: first after an unstructured waiting room situation and next after a ‘getting acquainted’ conversation. Results showed that high SAs (n = 24) elicited a more negative first impression than low SAs (n = 22). Also, although high SAs improved from the first to the second task, they were rated as less likeable after both interactions. The level of self-disclosure behaviour was the strongest predictor for the development of likeability during the sequential social tasks. The absence of an interaction between group and self-disclosure in predicting the development of likeability suggests that this is true for both groups. Thus, high SAs can improve their negative first impression if they are able to increase their self-disclosure behaviour. However, SAs showed a decreased level of self-disclosure behaviour during both social interactions. Targeting self-disclosure behaviour may improve the negative impression SAs elicit in others."
And it's not just about encouraging people struggling with social anxiety to be more self-disclosing and also (as the full text of this research study makes clear) show real interest in others' self-disclosure through questioning and caring, empathic responding. I remember a personal example. My brother & sister are both older than me. One evening when they were older teenagers and I was a young teenager they had invited a load of their friends round to the house of a party. I was "hiding" in the kitchen, half-heartedly helping my mum with the food. My mum was a very loving & supportive woman but, on this occasion, she rather shocked me by speaking to me pretty directly & a little sharply saying something like "These people are your guests too. Some of them are struggling a bit. As their host you should be out there, welcoming them, and helping them feel more at ease here." My memory is of rather creeping out of the kitchen with my tail between my legs feeling very self-conscious. Sure enough there certainly seemed to be some of the guests who looked pretty shy and a bit isolated. I went up to one or two of them and made encouraging, polite conversation. A few minutes later I was startled to notice that all my personal shyness seemed to have evaporated as I focused on being considerate and welcoming for these other people. Mm ... !
Over five years ago I quoted the Beatles words "The love you take is equal to the love you make" in a blog post - "Recent research: egosystem & ecosystem" - about Jennifer Crocker's inspiring work at Ohio State University. As she wrote last year in her paper "Consequences of self-image and compassionate goals" - "Interpersonal goals are a key mechanism through which people and their social environments influence each other. Two goals - self-image and compassionate goals - the motivational systems that energize these goals, their measurement, and how they relate to other constructs in the literature are described. Results of three longitudinal studies of first-year college students suggest that when people have self-image goals - that is, when they try to manage the impressions others have of them - they create a cascade of unintended negative consequences for both themselves and others. In contrast, when people try to contribute to the well-being of other people, they create a cascade of positive consequences for both themselves and others. Over time, for better or worse, by changing what they experience, people actually change themselves - the beliefs they hold and their goals, self-esteem, and even dispositional tendencies. We describe a variety of processes through which people's interpersonal goals shape their own and others’ experience and raise several remaining issues for this program of research."
and remember the personal story about people at my brother & sister's party ...
Alden, L. E. and C. T. Taylor (2011). "Relational treatment strategies increase social approach behaviors in patients with generalized social anxiety disorder" J Anxiety Disord 25(3): 309-318. We incorporated strategies based on relational and interpersonal circumplex research within a standard cognitive-behavioral regimen for Generalized Social Anxiety Disorder (GSAD, Generalized Social Phobia) to determine whether these techniques increased the social approach behaviors that facilitate relationship development. Individuals seeking treatment for GSAD were randomly assigned to either the integrated interpersonal cognitive-behavioral group treatment (ICBT) or a wait list condition (WL). Results revealed that the interpersonal techniques were readily implemented by the majority of patients. ICBT produced significant increases in frequency of social approach behaviors and relationship satisfaction, in addition to GSAD symptom reductions comparable to other group CBT regimens. The current research highlights the feasibility and potential benefit of incorporating strategies based on relational and circumplex theories into cognitive-behavioral regimens for GSAD.
Good. It seems well worth getting a sense of how this could be important (not least by experimenting with going against my own old habits of tending to keep my clothing & environments quite cool in temperature). David Clark talks about taking a good half hour or so going over the cluster of questionnaires that clients have filled out and jotting down key aspects on the "Social anxiety overall summary" with its four headings - feared situations, avoided situations, negative thoughts (worst fears), and safety behaviours. From all this information and especially from carefully going over one or more recent episodes of social anxiety, one now constructs - with the social anxiety sufferer's help - a personalised version of the "Social anxiety flow chart".
And in David Clark's work with social anxiety, he encourages clients to actually explore the differences they experience when they really "indulge" in safety behaviours and when they tough it out and drop as many safety behaviours as they are ready to. I would like to use this behavioural experiment approach more broadly than just for social anxiety sufferers (not something that I currently do at all).
"Courage is not the absence of fear, but rather the judgement that something else is more important than fear." James Hollingworth
More to follow ...
Last updated on Sun, 24/11/2013 - 08:25
The Norwegian Cardiac Exercise Research Group was established early in 2008 with funding from the Norwegian Research Council and other grant organizations. The work of their team of 36 research scientists "focuses on identifying the key cellular and molecular mechanisms underlying the beneficial effects of physical exercise on the heart, arteries and skeletal muscle in the context of disease prevention and management through experimental, clinical and epidemiological studies. Identifying the cellular and molecular mechanisms associated with aerobic fitness is important, because it may help us develop new and better methods to prevent and treat cardiovascular disease. The relationship between physical activity and health can be studied by either top-down or bottom-up approaches. The top-down approach starts with epidemiological studies, and then works its way towards identifying possible general physiological mechanisms. The bottom-up strategy begins with the basic molecular mechanisms induced by exercise, which are then placed in the greater context of improving public health ... We wish to address the lack of an integrated approach in fighting major public health issues such as inactivity, obesity, metabolic syndrome and subsequent cardiovascular disease, and the ensuing economic and social burdens on society in terms of treatment for lifestyle-related disease."
The researchers have published a stream of interesting studies, the most recent being "Estimating VO2peak from a nonexercise prediction model: The HUNT study, Norway". What the authors have found is that it seems that one can make a pretty good estimate of someone's cardiorespiratory fitness from key variables like age, waist circumference, exercise frequency/intensity and resting pulse rate without having to resort to expensive and hard to access fitness testing equipment. The New York Times has picked up on this research and put out an intriguing article entitled "What's your 'fitness age'?". This is freely accessible in full text and it's a good read, starting "Trying to quantify your aerobic fitness is a daunting task. It usually requires access to an exercise-physiology lab. But researchers at the Norwegian University of Science and Technology in Trondheim have developed a remarkably low-tech means of precisely assessing aerobic fitness and estimating your "fitness age," or how well your body functions physically, relative to how well it should work, given your age", and continuing "In order to figure out how to estimate VO2 max without a treadmill, the scientists combed through the results to determine which of the data points were most useful. You might expect that the most taxing physical tests would yield the most reliable results. Instead, the researchers found that putting just five measurements - waist circumference; resting heart rate; frequency and intensity of exercise; age; and sex - into an algorithm allowed them to predict a person's VO2 max with noteworthy accuracy, according to their study, published in the journal Medicine & Science in Sports & Exercise."
The NYT author is probably somewhat over-hyping the study (which isn't a predictive one) but makes interesting points when she writes "The results can be sobering. A 50-year-old man, for instance, who exercises moderately a few times a week, sports a 36-inch waist and a resting heart rate of 75 - not atypical values for healthy middle-aged men - will have a fitness age of 59. Thankfully, unwanted fitness years, unlike the chronological kind, can be erased, Dr. Wisloff says. Exercise more frequently or more intensely. Then replug your numbers and exult as your "age" declines. A youthful fitness age, Dr. Wisloff says, "is the single best predictor of current and future health." Check out your own 'fitness age' with the Cardiac Research Group's online calculator. Intriguing ... and the other sections on exercise advice from the Group are worth looking at too, including their 7 week fitness programme. Additionally there's lots of information about exercise here on the "Good Medicine" website ... see, for example, "15 minutes of exercise daily reduces mortality by 14% - and each additional 15 minutes gives 4% additional mortality benefit" and "Would you like to be 14 years younger - it's largely a matter of choice!" For advice on how to, how much, is it safe, motivation, and more click on this website's exercise tag.
Last updated on Mon, 28/10/2013 - 19:19
I have been asked to write a column on "Keeping up with the literature" for CBT Today "the official magazine of the British Association for Behavioural & Cognitive Psychotherapies". I sent in a first copy a couple of months ago, but unfortunately the editors couldn't get the space to squeeze it in. Today's post is an extension of that first copy, with several additions to the original publications that were initially recommended. As before, I thought it might be helpful to put an online version onto this website so that I can include relevant hyperlinks to the various research articles that I mention.
There's a great river of new CBT-relevant research flowing past all the time. In this quarterly column I comment on four themes that have recently caught my attention. These involve articles on social anxiety disorder, obsessive compulsive disorder, questionnaire reference values and effects of early life conflict & abuse.
Social anxiety disorder is very much in the news with May's new NICE guideline - "Social anxiety disorder: recognition, assessment and treatment" - and its clear statement that we should "Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model)". Since then, the large scale (495 patients) American Journal of Psychiatry study - "Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: A multicenter randomized controlled trial" - further underlines the particular value of CBT for this problem. Somewhat dauntingly, the May guideline underlined that "Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should ... receive regular, high-quality outcome-informed supervision ... and ... engage in monitoring and evaluation of treatment adherence and practitioner competence." The guidance comments that 12% of us are likely to suffer from social anxiety disorder at some stage in our lives, and that the disorder is highly persistent. Maybe the potentially overwhelming demand for trained therapists could partly be eased via internet delivered treatment. This certainly looks increasingly possible following the pilot study by Richard Stott & colleagues published in Behavioral & Cognitive Psychotherapy - "Internet-delivered cognitive therapy for social anxiety disorder: A development pilot series" (freely available in full text online). I went to a workshop with David Clark in the summer and there is a pretty full freely downloadable set of the dozen or so questionnaires that he recommended (and a copy of the "Cognitive Therapy Competence Scale for Social Phobia") at "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder".
Obsessive compulsive disorder is another problem that has recently benefited from the publication of new guidance. In this case it's an update to the 2007 American Psychiatric Association guideline - see Koran & Simpson's "Guideline watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder." This useful 22 page document is freely available online. In another paper, "Age of onset in obsessive-compulsive disorder", the authors Anholt et al. suggest that OCD development before age 20 constitutes "early onset" and is associated with a more severe clinical picture. Meanwhile Olatunji et al. in "Behavioral versus cognitive treatment of obsessive-compulsive disorder: An examination of outcome and mediators of change" highlight the importance of behavioural exposure & response prevention and uncover some surprising mechanism findings. Finally if like me, you suspect we can all be a bit OCD'ish at times, then you may enjoy the free full text findings of Lindeman et al. in their paper "Atheists become emotionally aroused when daring god to do terrible things."
I am a big fan of Routine Outcome Monitoring (ROM) as a way to track the effectiveness of our treatments and, especially, to pick up non-response as early as possible. Questionnaire reference values are important here and the Dutch Leiden group have published a whole series of helpful articles on this in the last few years. There are three papers I have noted this year, all by Schulte-van Maaren et al. - "Reference values for anxiety questionnaires: The Leiden routine outcome monitoring study", "Reference values for major depression questionnaires" (giving cut-off values for the BDI-II of 15 for women and 12 for men), and the background "Reference values for mental health assessment instruments: Objectives and methods of the Leiden routine outcome monitoring study." If you find it hard to pay for all these papers, there's a free full text overview from the same research team published in last year's BMC Psychiatry that's worth looking at - "Reference values for generic instruments used in routine outcome monitoring: The Leiden routine outcome monitoring study." Although I would argue that Routine Outcome Monitoring already has the potential to boost our effectiveness as therapists more than most other new initiatives that we could try - see the 48 slide talk "How can we help our clients more effectively?" - there is still a huge amount to learn here, including a better understanding of likely trajectories of improvement, as shown in the recent paper "Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression."
The last of the four themes I'm mentioning is recently published work on the effects of early life conflict & abuse. There are a series of articles linking trauma to psychosis and to bipolar disorder - for example Kelleher et al's "Childhood trauma and psychosis in a prospective cohort study: Cause, effect, and directionality" and Larsson et al's "Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder." There are also a bunch of studies on forms of bullying - for example Copeland et al's "Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence" and Lang et al's "Influence of problematic child-teacher relationships on future psychiatric disorder: Population survey with 3-year follow-up." And additionally there's a somewhat shocking paper on the biological effects of trauma by Heim et al. "Decreased cortical representation of genital somatosensory field after childhood sexual abuse" with its conclusion "Neural plasticity during development appears to result in cortical adaptation that may shield a child from the sensory processing of the specific abusive experience by altering cortical representation fields in a regionally highly specific manner. Such plastic reorganization may be protective for the child living under abusive conditions, but it may underlie the development of behavioral problems, such as sexual dysfunction, later in life." Worrying ... but there's hope too in very recent developments in our understanding of how much experience can effect gene expression positively as well as negatively, sometimes in a matter of minutes. See, for example, the fascinating interviews reported in "The social life of genes" with comments about the powerful mind-body effects achievable through psychotherapy and Professor Steve Cole of UCLA's admonition that "A cell is a machine for turning experience into biology" and, more challengingly, that "Your experiences today will influence the molecular composition of your body for the next two to three months or, perhaps, for the rest of your life. Plan your day accordingly."
Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours (4th post)Originally added on Sun, 13/10/2013 - 06:24
Last updated on Mon, 02/12/2013 - 07:11
I have written three posts recently on Self-practice/Self-reflection (SP/SR) and cutting edge CBT for social anxiety disorder - the most recent went onto the website yesterday. There is also a further associated post - "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder" - which gives ten or so relevant downloadable questionnaires & handouts. I mentioned that David Clark suggested (at the workshop I attended with him) that there are "five treatment innovations" in his approach to social phobia treatment - 1.) self-focused attention & safety behaviours experiments; 2.) video (and still) feedback; 3.) attention training; 4.) behavioural experiments; and 5.) then v's now discrimination training & rescripting for early socially traumatic memories. I already wrote a good deal about safety behaviours and avoidance yesterday. In today's post I continue to explore this territory.
David Clark's team use the 28 item "Behaviours questionnaire" (PDF file and Word doc) to help them assess individuals' use of safety behaviours. Also freely available on the web - from the Australian "Centre for emotional health" - is Ronald Rapee & colleagues' slightly longer 32 item "Subtle avoidance frequency examination (SAFE)" (PDF file and Word doc). I slightly prefer this latter scale because there is some research (reproduced on the version of the "SAFE" questionnaire downloadable from this website) giving likely frequency scores for people suffering from social anxiety and for a "normal" population. While talking about other academic centres with a focus on social anxiety, I would also like to mention David Moscovitch & colleagues' work. They have been publishing interesting contributions to our understanding of social anxiety for about ten years now. David Moscovitch's webpage at the University of Waterloo in Canada gives more details of his approach and ... wonderfully ... gives free full text access to his numerous research studies.
Of particular relevance is his 2009 paper "What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment" with its abstract reading "What, exactly, do individuals with social phobia fear? Whereas fear of anxiety-related bodily sensations characterizes and defines panic disorder, is there a fundamental focus of anxiety that unifies individuals under the diagnostic category of social phobia? Current conceptualizations of social phobia suggest several possible candidates, including the fear of negative evaluation, embarrassment, and loss of social status. However, it is argued here that these conceptualizations are fundamentally flawed and confusing, and the lack of clarity with respect to this question has hampered our ability to conceptualize and treat patients with social phobia in a manner that is tailored to individual differences in symptom presentation. In the present article, I will propose a novel conceptualization of core fear in social phobia, demonstrate how this conceptualization can be used to classify individuals with social phobia in a manner that eliminates confusion and accounts for symptom heterogeneity, and illustrate its potential utility for both clinical practice and research." I like this elegant paper with its teasing out of the distinction between feared stimulus, feared consequences, fear triggers/contexts, and fear-related avoidance, escape & safety behaviours. So he writes " ... understanding can be facilitated in the early stages of therapy by conducting a functional analysis, in which precise information is gathered on every patient's: (a) feared stimulus (defined here, as elsewhere [e.g., Barlow, 2002], as the precise focus or object of the patient's anxiety or that which the patient perceives as being "dangerous"); (b) feared consequences (defined as that outcome or set of outcomes that the patient is afraid will transpire if the feared stimuli are confronted); (c) fear triggers and contexts (defined as the cues, contexts, and situations that are associated for the patient with his or her feared stimuli and, therefore, likely to trigger feelings of anxiety and use of avoidance behaviors); and (d) fear-related avoidance, escape, and safety behaviors (defined as the emotional action tendencies in which a patient engages to try to prevent the occurrence of feared consequences)."
Moscovitch argues ... pretty convincingly to my mind ... that "the precise focus or object of the patient's anxiety" isn't negative evaluation by others, loss of social rank/status, or embarrassment. He suggests that these are all more "feared consequences" . He goes on to state "Thus, to answer our central question regarding the feared stimulus in social phobia, the empirical evidence cited above converges with clinical observation to suggest that individuals with social phobia are uniquely and primarily concerned about characteristics of self that they perceive as being deficient or contrary to perceived societal expectations or norms. According to this conceptualization, certain attributes of self are the focus of concern in social phobia in the same way that physical sensations are the focus of concern or fear in panic disorder and intrusive thoughts are the focus of concern or fear in OCD. Accordingly, negative evaluation, rejection, embarrassment, and loss of social status are consequences that individuals with social phobia fear will occur if those self-attributes are exposed for scrutiny by critical others. Whether a particular situation is thought of as being threatening depends crucially upon the nature of each patient's feared self-attributes and whether the patient believes he or she will be successful at concealing such attributes from public exposure. It follows from these premises that safety behaviors are self-protective, self-concealment strategies that serve the intended function of preventing the public exposure and criticism of feared self-attributes. The types of safety behaviors that are used by each patient depend on the specific self-attributes that are the focus of concern." In his paper "The negative self-portrayal scale: Development, validation, and application to social anxiety", Moscovitch argues that these fears about exposed "deficient attributes" typically occur in three general areas - "Social competence" (for example around being seen as "boring", "stupid" or "socially awkward"), "Physical appearance" (for example fears around being seen as "physically unattractive", "unfashionable" or "ugly") and "Signs of anxiety" (for example fears around being seen as "sweating", "stuttering" or "blushing"). Interesting territory. He has developed the "Negative self-portrayal scale (NSPS)" (PDF file and Word doc) to help clarify the particular concerns of individual social anxiety sufferers.
The next post in this sequence is at "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: more on avoidance & safety behaviours (5th post)"
Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: personal aims (3rd post)Originally added on Sat, 12/10/2013 - 04:29
Last updated on Mon, 02/12/2013 - 07:14
I have recently written a series of three blog posts on David Clark's very impressive cognitive therapy treatment for social anxiety disorder. One of the posts is very practical, giving ten or so relevant downloadable questionnaires & handouts - see "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder". The other two are the first pair of posts in a more extended sequence - "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: introduction (1st post)" and "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: assessment (2nd post)". Today's post continues this theme, looking at my personal aims for developing greater skill with this exciting treatment approach. I hope that writing about this will be helpful for me, helpful for other cognitive therapists who want to upgrade their ability to help social anxiety sufferers, and helpful in illustrating an approach to "deliberate practice" - a key component of effective skill development in almost any field (see, for example, the lecture I gave this summer on "How can we help our clients more effectively?")
To assess & monitor skill development, I intend to focus on the "five treatment innovations" David emphasised - 1.) self-focused attention & safety behaviours experiments; 2.) video (and still) feedback; 3.) attention training; 4.) behavioural experiments; and 5.) then v's now discrimination training & rescripting for early socially traumatic memories. And if, as I plan to, I'm using video more - especially with social anxiety treatment - I will have pretty clear records of my own work as a therapist to look at. I can evaluate the recordings using the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). I have stayed in touch with a colleague who also went to the July workshop with David, so we should be able to support each other as we try to apply what we learned. As this blog post highlights, I am also using Self-practice/Self-reflection (SP/SR) tools to encourage this skill development as well.
The initial module in the draft SP/SR workbook looks at ways of assessing & monitoring progress in the areas that one has chosen to focus on. The assessment methods they suggest are obviously designed to be applicable to the wide variety of issues that readers might be working with. I think I may do better to use my own initial measurement methods. I plan to use two. One is to scan the CTCS-SP for obvious areas of weakness. Unsurprisingly what stands out for me here are how I feel I fare with the three specialised social phobia areas 11. "Focus on social-phobia-related cognitions, self-focused attention, safety behaviors, and biased imagery." 13. "Selection of appropriate strategies for change in social-phobia-related cognition and maintaining factors (including selection of behavioral experiments and other experiential exercises). 14. "Appropriate implementation of techniques for change in social-phobia-related cognition and maintaining factors (including selection of behavioral experiments and other experimental exercises).
Secondly, for overall social anxiety treatment skills I will mark myself on a simple 0 to 10 scale for each of the "five treatment innovations". One interesting insight that emerges when I do this, is that these treatment innovations can also be helpful in other problem areas. So "safety behaviours experiments", "video (and still) feedback", "attention training", "behavioural experiments" and "then v's now discrimination training & rescripting for early memories" can all be applied at times in, for example, health anxiety, OCD, PTSD and so on. This is great. I'm a pretty busy therapist and I would be confident that I put in more face-to-face therapy hours per week seeing clients than the vast majority of psychotherapists (28 x 75 minutes in a full week), however it is relatively infrequent that I get a "pure social anxiety case" to focus on. If I can improve the relevant skills in a wider set of therapeutic situations than just pure social anxiety then I'm likely to develop more quickly. This is likely to be true for virtually all cognitive therapists who don't work in specialist social anxiety treatment clinics (which must be almost as rare as hen's teeth).
So taking the five social anxiety "treatment innovations" one at a time - first "safety behaviour experiments". OK this is potentially relevant across so many areas of psychotherapy - see, for example, the 2010 paper "Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders" with its abstract reading "Cognitive-behavioral models emphasize maintaining effects of safety behavior in anxiety disorders. Experimental evidence for deleterious effects of those behaviors is less consistent, leading to a controversy about their therapeutic use. The systematic integration of findings is hampered by the variety of concepts used to describe safety behavior, and methodological differences in empirical studies. This article provides a definition and classification of safety behavior in contrast to adaptive coping strategies. Existing evidence regarding contributions of safety behavior to onset and maintenance of anxiety disorders as well as effects of safety behavior on therapeutic outcome is reviewed. In contrast to previous justifications of safety behavior use, a rigorous procedure of identifying safety behavior and abandoning it throughout therapy is suggested." Then there is the more internally relevant "Does experiential avoidance mediate the effects of maladaptive coping styles on psychopathology and mental health?" with its comment that "These results suggest that a person who is prone to use EA (experiential avoidance) or has learned EA in stressful situations has a higher risk of developing psychopathology and lower mental health. This indicates that early interventions that aim at people with high levels of EA are highly relevant." The "Acceptance & action questionnaire" is often helpful in quantifying this territory better ... and this is so central ... the way that fear & anxiety can so easily "shrink" our lives. I like the Confucius quote "Wisdom, compassion, and courage are the three universally recognized moral qualities of men" (and women), and I note that in David Barlow's lauded "Unified protocol for transdiagnostic treatment of emotional disorders", tackling forms of avoidance is right at the heart of the therapy.
It's relevant too when one moves up from trying to ease suffering & dysfunction to trying to improve flourishing & wellbeing. In the more positively orientated "Affect regulation strategies for promoting (or preventing) flourishing emotional health", the authors note "Significant differences between moderate and flourishing groups consisted of behaviors that ‘prevented' rather than ‘promoted' flourishing (e.g., behavioral and cognitive avoidance). These findings suggest that in order to achieve flourishing, individuals may need to reduce avoidance strategies and increase engagement strategies." This kind of finding then makes it less of a surprise when it is so strongly demonstrated via meta-analysis that reducing avoidance can be a powerful intervention for promoting positive psychological states (as well as reducing distressing states) ... see the 2010 paper "Behavioral activation interventions for well-being: A meta-analysis" and the even more recent "Would introverts be better off if they acted more like extraverts? Exploring emotional and cognitive consequences of counterdispositional behavior." (The answer, by the way, is "yes, it appears that they would!").
So tackling avoidance & safety behaviours and promoting behavioural activation & value-driven activities is clearly rich and widely relevant territory. For the next in this sequence of blog posts, see "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours (4th post)".
Last updated on Fri, 22/11/2013 - 06:44
common sense on improving outcomes: It only takes a little reflection to realise that, if we want to become more successful at doing something, it’s likely to help immensely if we know where we’re starting and can track if we’re improving or not. The research literature is very clear about the importance of this approach – see, for example, the major text book “Development of professional expertise: Toward measurement of expert performance and design of optimal learning environments” – but common sense already makes this pretty obvious. Imagine that we are trying to improve our skills at playing darts. Obviously we need to practise throwing darts at a board so that we can learn to place them more accurately & achieve increasingly excellent scores.
Now imagine that we’re asked to develop dart-throwing skill but we have to wear blindfolds while we’re practising and we only get rather vague reports from others as to where the darts are hitting the board. In this situation, it might take an awfully long time to improve. In fact maybe we wouldn’t actually improve at all. This is a pretty good description of our attempts to become more expert in the majority of occupations and professions. Most people believe that they are getting better & better results the longer they work at their job. Sadly research study after research study shows that this is usually an illusion. There is typically very little relationship between years spent in practice and how successful we are at achieving good outcomes. Most of us – including nearly all health professionals – are like blindfolded dart players. Is this person that I’m working with becoming better because of the help that I’m providing, or would they have got better anyway? Maybe my input has actually slowed their recovery? How do I know? Happily this confusing, blindfolded, learning situation is starting to change and this improvement is well worth supporting.
relevance for psychotherapy: For psychotherapists, there is a very sensible and increasingly powerful research-based initiative encouraging us to track the results we achieve more carefully and check how they measure up to best outcomes in our field. This can meld the best of evidence-based practice with the fine-tuned personalization achievable through practice-based evidence. As Castonguay and colleagues write in their chapter on “Practice-orientated research” in the superb 2013 edition of the “Handbook of psychotherapy and behavior change” – “At its heart, practice-based evidence is premised on the adoption and ownership of a bona fide measurement system and its implementation as standard procedure within routine practice.” So what we need to do is monitor how effective we’re being as psychotherapists with well-established outcome measures that are also being used by many other psychotherapists working in similar fields to ourselves. In this way we can compare our results and see where we’re doing well and where we need to improve. The “dart players” who want to improve their success rates can now do so without having to wear blindfolds. The previously very hard task of assessing whether we’re getting better at what we do as therapists can become a whole lot easier.
ways to monitor our practice: There are a number of “bona fide measurement systems” available to us including the “Clinical Outcomes in Routine Evaluation (CORE)”, the “Outcome Questionnaire-45 (OQ45)”, the “Partners for Change Outcome Management System (PCOMS)”, and the “Treatment Outcome Package (TOP)”. These assessment & tracking methods, and others in development, are still evolving. However, very encouragingly, they are already making a major impact to boosting outcomes and significantly reducing deterioration rates (see Castonguay et al, above). One way they do this is by highlighting cases where improvement is not occurring adequately – typically by charting how each client is actually responding when compared with improvement trajectories predicted from databases of large numbers of similar cases.
We have known for many years that significant improvement in the first handful of therapy sessions (two to five maybe) is a good predictor of eventual overall progress - see, for example "Early improvement during manual-guided cognitive and dynamic psychotherapies predicts 16-week remission status" and "Do early responders to psychotherapy maintain treatment gains?" This has tended to push me towards using "bona fide measurement systems" like the CORE and PCOMS (see above) so that I can track my client's progress against predicted trajectories. Reading recent emerging research on variability in response patterns in eventually successful cases however has made me a bit more cautious about this somewhat one-style-fits-all viewpoint - see this year's papers"Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression" and "Shape of change in cognitive behavioral therapy for youth anxiety: Symptom trajectory and predictors of change."This new caution makes me more ready to consider other ways of assessing the effectiveness of my therapy.
using IAPT data to benchmark how well we're doing: A fine recent overview of success rates obtained by UK Increasing Access to Psychological Therapies (IAPT) introduces a new option – see “Enhancing recovery rates: Lessons from year one of IAPT" (freely downloadable in full text) with the paper's abstract reading: "Background The English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines. Method Data from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7). Results Data completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff. Conclusions Compliance with the IAPT clinical model is associated with enhanced rates of reliable recovery."
This new IAPT data allows us to use free monitoring questionnaires like the PHQ-9 and GAD-7 to track how therapy is going and - fascinatingly - to compare our overall success rates against a very large database of similar cases. It still makes very good sense to be eagle-eyed about initially slow therapeutic response, while also acknowledging that eventually successful cases don't all follow similar improvement trajectories. In the next post in this sequence I will look more closely at the IAPT data and how we can use it to "take off our blindfolds" and start improving our success at "hitting the dartboard" in helping our clients more consistently achieve excellent outcomes.
Last updated on Fri, 22/11/2013 - 05:54
Every few weeks I scan through all the articles I've found interesting in the previous month (in the general areas of stress, health & wellbeing) and then filter them into four narrower, more specific mailings. One is primarily for cognitive-behavioural therapists linked with the British Association for Behavioural & Cognitive Psychotherapies (BABCP) and other CBT organizations around the world. This set of abstracts focuses particularly on cognitive therapy in its many applications (anxiety, depression, psychotic disorders, etc). Click on BABCP mailing to see the 30 abstracts (mostly from September) that I have listed.
A second, and more recent development, is for people who have expressed an interest in keeping up to date with research relevant to compassion - see the post "Proposal for a BABCP special interest group on compassion" - this month there are 17 abstracts in the Compassion mailing.
A third mailing is to various people involved with Action on Depression Scotland (AOD). AOD is the only charity specifically working for people with depression who live in Scotland. I've been on their Clinical Advisory Board for some years. These abstracts focus more on depression and many are about antidepressant medication as well as others which overlap with the BABCP mailing on psychotherapy. Click on AOD mailing to see the 30 abstracts recently sent out.
The fourth mailing is to the editor of the British Holistic Medical Association (BHMA) newsletter. Back in the early 1980's I was on the working party that set up the BHMA. I'm not much involved with them now - partly because many of their original objectives have been achieved and are now mainstream. This month's BHMA mailing contains 50 abstracts covering a multitude of stress, health & wellbeing related subjects including a whole cluster on mindfulness, a comparison of CBT with psychodynamic therapy, a couple of studies on benefits from therapeutic writing, factors in client & therapist that increase dropout rates, several studies on the effects of dietary supplements, reduced suicide rates in coffee drinkers, possible adverse effects of wearing red in work environments, the importance of health professionals' positive voice tone, social network changes across the lifespan, how leaf-stroking can benefit plants, and much more.
Last updated on Mon, 28/10/2013 - 17:52
I went to a workshop on the treatment of social anxiety disorder with David Clark in July. It was very helpful. I've listed assessment & monitoring questionnaires that he recommended below:
As a general measure to assess and track changes in social anxiety severity, the freely available Social Phobia Inventory (SPIN) is the questionnaire recommended by the England & Wales NHS Improving Access to Psychological Therapies (IAPT) "outcomes toolkit". Interestingly David seems to prefer the Liebowitz Social Anxiety Scale (LSAS) probably because it makes a pretty full job of assessing both anxiety and avoidance.
Social Phobia Inventory - SPIN - (PDF file and Word doc): a widely used, freely available 17 item questionnaire for assessing social anxiety disorder. On the second sheet of the download, I give suggestions about what the different levels of score mean.
Liebowitz Social Anxiety Scale - LSAS - (PDF file and Word doc): this 24 item questionnaire assesses both social anxiety and avoidance. It's good and is widely used in clinical trials. On the second sheet of the download, I give scoring suggestions and some information about improvement.
Participants on David's July workshop were subsequently sent copies of four further questionnaires he recommends using. These measures were emailed as a Word doc attachment in Arial font printing out as "letter" sized handouts. They are available to download in this format here. I have also rewritten them in my preferred Tahoma font printing out as A4 sized documents and have listed them individually below:
Social Phobia Weekly Summary Scale (PDF file and Word doc): this 6 item questionnaire uses 0 to 8 numerical rating scales to assess disturbance/disablement, avoidance, other-focused/self-focused attention in general & in difficult social situations, pre-event anticipatory worry, and post-event subsequent rumination.
Social Cognitions Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency and degree of belief in 22 thoughts that may go through people's minds when they feel socially frightened or anxious. There is additional space for writing down and rating less common, more personalized "catastrophic" social concerns.
Attitudes Questionnaire (PDF file and Word doc): an extensive 50 item assessment form. The instructions state - "This questionnaire lists different attitudes or beliefs which people sometimes hold. Read each statement carefully and decide how much you agree or disagree with each one ... Because people are different, there is no right or wrong answer to these statements. To decide whether a given attitude is typical of your way of looking at things, simply keep in mind what you are like most of the time."
Behaviours Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency of 28 "safety behaviours" that people suffering from social anxiety may perform. It is suggested that these behaviours often seem like they help the anxiety in the short term, but in the longer term there is a real danger that they maintain the problem.
David also gave us a book chapter handout entitled "The assessment interview and getting started". Interestingly in the table on "Standardized questionnaires that are useful for collecting information in advance of the Clinical Interview" he mentions the LSAS, Cognitions, Attitudes, and Behaviours Questionnaires (all listed above). This group of four questionnaires seems to be the standard assessment bundle (plus the Weekly Summary Scale). They can be partly concentrated down to the Social Anxiety Overall Summary sheet (see below) and then individualized still further when completing the Social Anxiety Flow Chart (below).
However in the chapter table, the assessment list also includes the Beck Depression Inventory and the 1998 Mattick & Clarke Social Phobia Scale and Social Interaction Anxiety Scale. Many therapists will have alternative assessment instruments for depression other than the relatively expensive copyrighted Beck Inventory - for example IAPT recommends the PHQ-9. At the risk of gilding the lily, here are the two Mattick & Clarke questionnaires, which can in some situations provide additional useful assessment, monitoring & treatment planning details:
Social Phobia Scale (PDF file and Word doc) and the Social Interaction Anxiety Scale (PDF file and Word doc): these two 20 item scales assess social situations and aspects of social situations that are anxiety provoking.
Even if one only uses some of the above questionnaires, there is now a lot of information that has been recorded. In the book chapter handout we were given, it is suggested that it may be helpful to summarize much of what is most important from this extensive initial assessment on the following sheet:
Social Anxiety Overall Summary (PDF file and Word doc): this form provides a place to summarize information from the various questionnaires under the four general headings - feared situations, avoided situations, negative thoughts (worst fears), and safety behaviours.
Now as a cooperative effort with the social anxiety sufferer, it is recommended that one draws out a "flow chart" of what happens when they become particularly self-conscious & embarrassed. Many cognitive therapists will do this using a wall mounted whiteboard. There are advantages to developing the flow chart this way - for example in externalizing the problem and side-stepping what might feel, to the client, an over-intense eye-to-eye interview. My preference is to sit beside the client and draw out the flow chart on a piece of paper (see below) held on a clipboard. Using this format one has a sheet that can be photocopied and handed to the client to take away, think about and potentially add to. Producing the social anxiety flow chart together may well take 40 minutes or so to do well. At this stage, it is a process of description and "finding out" together rather than an explanation. Try not to rush the process - when it's done well it can lead to the sufferer feeling very understood. It is recommended that one select a specific example of a socially embarrassing situation that the client has experienced and can remember fairly easily (a recent event is often good to focus on here). One starts with a brief description of the situation (top of flow chart). Moving on to the physical anxiety symptoms that were experienced may well be a good next step (interestingly the Beck Anxiety Inventory may be useful here too). Then one can enquire and fill in details of thoughts (about perceived social dangers) and sense of self-consciousness (quite possibly linked with an image and/or felt-sense about how one is coming across to others). One might then move on to producing quite an extensive list of safety behaviours that were involved. One can add further information from other social anxiety events they have experienced and it may well be useful to give them the sheet to take home and add to after they have been through new socially challenging experiences.
Also likely to be useful is a sheet that can be used for recording behavioural experiments - a core component of this highly successful cognitive therapy treatment for social anxiety disorder:
And lastly in this list, is a copy of the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). To measure therapist skill in treating social anxiety, Clark & colleagues have impressively developed a specific assessment scale - see "Assessing therapeutic competence in cognitive therapy for social phobia: Psychometric properties of the cognitive therapy competence scale for social phobia (CTCS-SP)." Then, crucially, they have shown that skill measured in this way is predictive of patient outcomes - see "Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder." As the authors of the "Treatment competence" paper comment " ... informal use of the cognitive therapy rating scale by students themselves is likely to be helpful. Certainly, we have found that many therapists who are learning CT for social anxiety learn a great deal about how particular procedures should be implemented by studying the particular items on the CTCS-SP and rating their own sessions according to the scale."
Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: assessment (2nd post)Originally added on Mon, 23/09/2013 - 05:15
Last updated on Tue, 05/11/2013 - 06:02
Yesterday I wrote an introductory post on using self-practice & self-reflection (SP/SR) to improve my understanding of David Clark's treatment for social anxiety. In today's post I want to look at assessment - of social anxiety disorder, of skill with Clark's CBT approach, and at SP/SR initiation.
Back in May, in a first post on the new NICE guideline, I wrote that to identify adults with probable social anxiety disorder it is recommended that one "Ask the identification questions (to clarify whether there is likely to be some form of anxiety disorder present) using the two-item generalised anxiety disorder scale (GAD-2) in line with NICE guidance (downloadable here as a Word doc or a PDF file), and if social anxiety disorder is suspected use the three-item mini-social phobia inventory (Mini-SPIN) or consider asking the following two questions: Do you find yourself avoiding social situations or activities? Are you fearful or embarrassed in social situations? If the person scores 6 or more on the Mini-SPIN or answers yes to either of the two questions above, refer for or conduct a comprehensive assessment for social anxiety disorder." Note the Mini-SPIN, the full SPIN and several other relevant questionnaires and handouts are downloadable from this website's "Good knowledge" page on "Social anxiety information & assessment".
I also wrote "Some degree of concern about how we are evaluated by others is normal. Humans are social animals and not to give a sh*t about what others think of us isn't adaptive. However being over-concerned isn't adaptive either. As usual "the middle way" is likely to be most helpful ... to pay some attention to how others are reacting to us, but not to be governed by their opinions. Sadly a worryingly high percentage of us will have excessive levels of social anxiety. Often this persists for many years. As highlighted in today's post, identification of those who are suffering troublesome social concerns makes very good sense." So there are pretty strong arguments about the value of better identification of social anxiety problems. I have already mentioned this website's "Good knowledge" page on "Social anxiety information & assessment" as a source of potentially helpful assessment questionnaires. At David Clark's July workshop on state-of-the-art cognitive therapy treatment for social anxiety disorder, he discussed assessment in some detail and I have written a blog post about this at "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder".
So that's a bit about clarifying severity of social anxiety, what about clarifying skill with Clark's CBT approach, and what kind of assessment is helpful in setting up Self-practice/Self-reflection (SP/SR)? To measure therapist skill in treating social anxiety, Clark & colleagues have impressively developed a specific assessment scale - see "Assessing therapeutic competence in cognitive therapy for social phobia: Psychometric properties of the cognitive therapy competence scale for social phobia (CTCS-SP)." Then, crucially, they have shown that skill measured in this way is predictive of patient outcomes - see "Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder." I don't see myself getting access to trained raters to evaluate videotapes of my therapy sessions (as used in the research trials), however both of these papers are freely downloadable in full text so one can see what the raters were looking for when using the CTCS-SP. As the authors of the "Treatment competence" paper comment " ... informal use of the cognitive therapy rating scale by students themselves is likely to be helpful. Certainly, we have found that many therapists who are learning CT for social anxiety learn a great deal about how particular procedures should be implemented by studying the particular items on the CTCS-SP and rating their own sessions according to the scale." Here is the CTCS-SP downloadable as a Word doc and here as a PDF file.
The CTCS-SP consists of 16 items that are assessed using a 7 point scale running from 0 indicating poor competence to 6 indicating excellent competence. In the reported research trial, therapists were expected to reach at least an average of level 3 on assessed videotapes. Dropping below competence level 3 triggered "feedback and additional supervision". The "Assessing therapeutic competence" paper states "The final scale consisted of 16 items: agenda; dealing with questions, objections, problems; clarity of communication; pacing and efficient use of time; interpersonal effectiveness; resource orientation; review of social-phobia diary, questionnaires and other measures; reviewing previously set homework; use of feedback and summaries; guided discovery; focus on social-phobia-related cognitions, self-focused attention, safety-behaviours, and biased imagery (cognitive model); rationale; selection of appropriate strategies for change in social phobia related cognition and maintaining factors; appropriate implementation of techniques for change in social phobia related cognition and maintaining factors; integration of discussion and experiential techniques; homework setting." The item labelled "resource activation" is interesting. It is not specifically a cognitive therapy technique, but in a previous CBT trial for social anxiety it was found to predict improved outcome. The authors describe it by saying "we expect the therapist to enable the patient to be aware of the patient's positive characteristics and skills and focus on how these can be used to reach self-set goals in therapy."
This overlaps very neatly with similar findings in depression - see the series of three posts from earlier this year starting with "New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses".
At his July workshop, Clark showed a slide where he highlighted "five treatment innovations" in his cognitive therapy approach for social anxiety - 1.) self-focused attention & safety behaviours experiments; 2.) video (and still) feedback; 3.) attention training; 4.) behavioural experiments; and 5.) then v's now discrimination training & rescripting for early socially traumatic memories. I'm a very experienced cognitive therapist and I have trained with David Clark in the past, but I'm not skilful with this current social anxiety treatment focus. Exciting. Great to know that I can do this better. Back in the 1990's, meta-analysis showed no additional benefit of adding cognitive approaches to basic exposure therapy for social phobia and this result was replicated in a further meta-analysis in the early 2000's.
In general, simple exposure therapies still stand up well when compared to more complex cognitive-behavioural interventions for anxiety disorders - see, for example, the 2011 paper "Efficacy of exposure versus cognitive therapy in anxiety disorders: Systematic review and meta-analysis." But the abstract of this paper makes it very clear that this is no longer the case for social phobia - "There is growing evidence of the effectiveness of Cognitive Behavioural Therapy (CBT) for a wide range of psychological disorders. There is a continued controversy about whether challenging maladaptive thoughts rather than use of behavioural interventions alone is associated with the greatest efficacy. However little is known about the relative efficacy of various components of CBT. This review aims to compare the relative efficacy of Cognitive Therapy (CT) versus Exposure (E) for a range of anxiety disorders using the most clinically relevant outcome measures and estimating the summary relative efficacy by combining the studies in a meta-analysis. METHODS: Psych INFO, MEDLINE and EMBASE were searched from the first available year to May 2010. All randomised controlled studies comparing the efficacy of Exposure with Cognitive Therapy were included. Odds ratios (OR) or standardised means' differences (Hedges' g) for the most clinically relevant primary outcomes were calculated. Outcomes of the studies were grouped according to specific disorders and were combined in meta-analyses exploring short-term and long-term outcomes. RESULTS: 20 Randomised Controlled Trials with (n=1,308) directly comparing the efficacy of CT and E in anxiety disorders were included in the meta-analysis. No statistically significant difference in the relative efficacy of CT and E was revealed in Post Traumatic Stress Disorder (PTSD), in Obsessive Compulsive Disorder (OCD) and in Panic Disorder (PD). There was a statistically significant difference favouring CT versus E in Social Phobia both in the short-term (Z=3.72, p=0.0002) and the long-term (Z=3.28, p=0.001) outcomes. CONCLUSIONS: On the basis of extant literature, there appears to be no evidence of differential efficacy between Cognitive Therapy and Exposure in PD, PTSD and OCD and strong evidence of superior efficacy of Cognitive Therapy in Social Phobia."
In fact, as of June 2013, David said that one-to-one cognitive therapy for social anxiety disorder had been assessed in seven randomized controlled trials (in the UK, Sweden & Germany) where it was shown to be superior to exposure therapy, two versions of group CBT, interpersonal psychotherapy, psychodynamic psychotherapy, medication (SSRI's), placebo, and no treatment (see too the major study reported in July's American Journal of Psychiatry). Typically there has also been careful balancing of therapist affiliation effects. As David points out, he doesn't know of any other psychological disorder with such clear differences between the preferred treatment and other active treatments. Wow! The crying shame is that there is huge client need in this area and very few therapists who have adequate experience in providing this type of treatment. Learning to upgrade my work to current state-of-the-art cognitive therapy for social anxiety disorder makes very good sense.
For specific details that take this general wish into nitty-gritty intentions, see the next post in this sequence "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: personal aims (3rd post)".
BABCP Scotland autumn conference: Paul Salkovskis "Master class for health anxiety & unexplained medical symptoms" (1st post)Originally added on Mon, 23/09/2013 - 05:06
Last updated on Fri, 22/11/2013 - 05:36
The Scottish branch of the British Association for Behavioural & Cognitive Psychotherapies (BABCP) organized a two day autumn conference over the 12th & 13th of September on "Current trends in CBT". Interestingly what was on offer consisted almost entirely of workshops (apart from one brief symposium on the first evening). On the first day Avinash Bansode gave a workshop on "MBCT" and John Swann taught on "CBASP".
On the second Chris Irons gave a workshop on "Compassion focused therapy for skilled practitioners" and Alison Brabban gave one on "CBT for psychosis". Across both days of the conference, Paul Salkovskis taught a "Master class for health anxiety and unexplained medical symptoms".
Gosh it rather dates me. Looking back into my database, I find an entry about my attendance at a one day workshop on "Cognitive therapy for panic and hypochondriasis" given by David Clark & Paul Salkovskis at the 1993 BABCP spring conference in London. I wrote at the time "They were a great knock-about act ... and also full of useful practical information and therapeutic help." Now twenty years later I am at another workshop on health anxiety with Paul. What has changed? What remains the same?
For me it was a funny workshop ... as in "funny", a bit strange. I have an image of a large plate of food, a good deal of it indigestible or lacking in nourishment (in helping me improve as a therapist). But mixed in are a whole series of really nutritional chunks ... facts, insights & suggestions for improving my treatment for people suffering from health anxiety and unexplained medical symptoms. Such a pity, for me anyway, that the workshop was such a mixture of helpfulness and "noise". Paul obviously understood that this was occurring. On several occasions he referred to his "rants" about health politics, other therapy schools, and so on. He even suggested we try to keep him on topic. Tough to do this as he can be fairly cutting in his responses at times. I know the colleague sitting next me was quite open about how reticent she was to ask a question in case she would feel humiliated. I'm glad I went to the workshop though. As I've written before about Paul as a presenter ... there's usually plenty that's worthwhile amongst what to me seems like a backdrop of expletive-rich dross. No doubt there are other participants who soak it all up appreciatively. We vary in what we find helpful.
More to follow ...