Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: personal aims (3rd post)
Last updated on 28th August 2014
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)".