wells brief cognitive therapy for social phobia -- a case series

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Behaviour Research and Therapy 39 (2001) 713720

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Shorter communication

Brief cognitive therapy for social phobia: a case seriesAdrian Wells a,* , Costas Papageorgiou b

a Department of Clinical Psychology, University of Manchester, Rawnsley Building, MRI, Oxford Road, Manchester M13 9WL, UK

b University of Manchester and North Manchester NHS Trust, UK

Received 17 January 2000

Abstract

Social phobia is a common and disabling anxiety disorder. The most effective psychological treatmentsfor social phobia are cognitive therapy and exposure. However, the degree of improvement across thesetreatments is variable, and their implementation is costly and time-consuming. This study aimed to conducta preliminary clinical evaluation of the effectiveness of a brief, new form of cognitive therapy based ona recent cognitive model of social phobia. Six consecutively referred patients with social phobia weretreated using established single case series methodology. Brief cognitive therapy was effective with allpatients demonstrating clinically signicant improvements in all measures. Treatment gains were maintainedat follow-up. The mean number of treatment sessions delivered was 5.5 and improvements compare favour-ably with previous treatment studies. Brief cognitive therapy for social phobia appears promising and it ispotentially cost-effective. Future randomised and controlled evaluations of this brief treatment are war-ranted. 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Social phobia; Cognitive therapy; Brief treatment; Self-consciousness

1. Introduction

Social phobia is a common and disabling anxiety disorder. In the absence of treatment socialphobia can persist for a number of years. Even when psychological treatment is available, socialphobia can pose complex therapeutic challenges. Evaluations of psychological treatments forsocial phobia show that the most effective interventions are cognitive therapy (CT) and exposure

Parts of this paper were presented at the Annual Conference of the British Association for Behavioural and Cognitive Psycho-therapies, Bristol, UK, July 1999.

* Corresponding author. Tel.: + 44-161-276-5399; fax: + 44-161-273-2135. E-mail address: [email protected] (A. Wells).

0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.PII: S0005-7 967(0 0)000 36-X


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(e.g., Heimberg & Juster, 1995; Taylor, 1996). Heimberg and Juster concluded that CT alone,and exposure alone produce equivalent results. In a meta-analysis of 42 treatment outcome trialsof these approaches, Taylor reported that combined CT and exposure-based methods produced

signicantly larger effect sizes than did CT, exposure-based methods, and social skills trainingalone. Nevertheless, the degree of improvement, particularly cognitive change, across these treat-ment modalities is variable and their implementation and delivery is both costly and time-consum-ing. Clark and Wells (1995) argued that psychological treatment for social phobia may be moreeffective if it is based on a model of the cognitive processes involved in the maintenance of thisdisorder. In view of this, they proposed a cognitive model highlighting specic cognitions, andmaladaptive attentional and coping strategies in the perpetuation of social phobia.

In Clark and Wells (1995) cognitive model, it is proposed that individuals with social phobiaprocess negative aspects of themselves on exposure to feared social situations. This self-processingusually occurs as an impression of appearance from an observer perspective, in which symptomsof anxiety and failed performance are thought to be highly conspicuous. Self-processing in social

situations is also linked to the execution of safety behaviours aimed at preventing social calamitiesand controlling or concealing symptoms. The problem with self-processing is that it diverts atten-tion away from processing external social information that could modify negative beliefs. Safetybehaviours are problematic since the non-occurrence of catastrophe can be attributed to use of the coping behaviour so that the individual fails to discover that social situations are not danger-ous. Such behaviours can exacerbate symptoms and contaminate the social situation. Aside fromin-situation self-processing, individuals with social phobia are also thought to engage in pre- andpost-event worry that maintains negative perceptions of the self. Recent evidence is consistentwith the idea that post-event processing is elevated in socially anxious individuals (Rachman,Gruter-Andrew & Shafran, 2000).

On the basis of their model, Clark and Wells (1995) developed a new version of CT for social

phobia (Wells, 1997; Wells & Clark, 1995). In brief, the treatment derived from this model isstructured as a sequence in which idiosyncratic conceptualisation and socialisation are followedby manipulations of safety behaviours and self-focused attention in feared social situations inconjunction with exposure as a behavioural test of negative self-beliefs. The next step in thesequence involves modifying the content of the distorted observer perspective self-image. Stra-tegies are also used in treatment to reduce pre- and post-event worry.

An initial evaluation of the effectiveness of this type of treatment revealed encouraging resultswith mean changes in fear of negative evaluation between 1.5 and 2 times greater than thosereported in previous outcome trials of cognitive-behavioural therapy (Clark, 1997). More recently,Clark (1999) reported preliminary data from the Oxford randomised, placebo-controlled trial com-paring the new type of CT with uoxetine plus exposure, and placebo plus exposure. These results

demonstrated that CT was signicantly superior to the other treatment conditions in reducingsymptoms of social phobia, including fear of negative evaluation.In this study, we aimed to evaluate the effectiveness of a brief form of CT based on the Clark

and Wells (1995) model. The existing treatment involves 1418 individual sessions. In order toabbreviate this treatment, modications were based on theory (Wells & Matthews, 1994), empiri-cal research supporting treatment components (Harvey, Clark, Ehlers & Rapee, 2000; Wells etal., 1995; Wells & Papageorgiou, 1998, 1999, 2000), and our clinical experience in deliveringthe intervention.


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2. Method

2.1. Design

In order to evaluate the effectiveness of a brief form of CT for social phobia, a single caseseries using an AB design (Barlow & Hersen, 1984) with follow-up was implemented. For thisdesign, all patients were assigned to no-treatment baselines ranging from 3 to 5 weeks. Individualbaselines acted as control periods, and were extended until stable trends in most outcome measureswere evident. During baseline periods, the therapist met with patients weekly in order to adminis-ter and collect relevant outcome measures. The duration of baseline contacts was limited toapproximately 10 min, and no treatment or discussion of the content of patients fears was permit-ted during this time. Following individual baseline intervals, brief CT was delivered weekly, witheach treatment session lasting up to 60 min. On completion of treatment, patients were followedup for 3 and 6 months. No CT was administered between post-treatment and follow-up intervals.

2.2. Patients

Six male patients who were consecutively referred for psychological treatment of socialanxiety/phobia were included in the case series. Referrals were made directly by local familyphysicians to Departments of Clinical Psychology in Central and North Manchester Hospitals.All patients satised DSM-IV (American Psychiatric Association, 1994) criteria for social phobia.Four of the patients met criteria for the generalised subtype of social phobia and two for the non-generalised or specic subtype. Diagnoses were made following the administration of the Struc-tured Clinical Interview for DSM-IV Axis I Disorders Patient Edition (SCID-I/P; First, Spitzer,Gibbon & Williams, 1997). All patients stated that social anxiety was their main problem. The

SCID-I/P severity of social phobia ranged from 4 (distress and functional interference about half of the time) to 5 (distress and functional interference a signicant majority of the time). Patientsages ranged from 18 to 44 years, and the duration of social phobia problems ranged from 2 to27 years. None of the patients had received any previous psychological treatments for socialphobia and they were not taking psychotropic medication.

2.3. Measures

A comprehensive battery of standardised and widely used self-report measures assessing differ-ent dimensions of social phobia were administered. These measures included the following: Fearof Negative Evaluation (FNE) and Social Avoidance and Distress (SAD) scales (Watson & Friend,

1969); Social Phobia (SPS) and Social Interaction Anxiety (SIAS) Scales (Heimberg, Mueller,Holt, Hope & Liebowitz, 1992; Mattick & Clarke, 1989); Beck Anxiety (BAI; Beck, Epstein,Brown & Steer, 1988) and Depression (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961)Inventories; and Social Phobia Rating Scale (SPRS; Wells, 1997). The SPRS consists of verating scales assessing key components of the Clark and Wells (1995) cognitive model of socialphobia in recent anxiety-provoking social situations. These scales include: distress (08), avoid-ance (08), self-consciousness (08), frequency of safety-seeking behaviours (08), and negativebeliefs (0100). For purposes of brevity, only SPRS avoidance, self-consciousness, and total nega-


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3. Results

Patients SPRS scores on social avoidance, self-consciousness, and total negative belief duringbaseline and treatment periods, and at follow-up are shown in Fig. 1. The baseline scores on theseweekly measures were predominantly stable across patients. Therefore, it is unlikely that the brief CT effects observed are the result of spontaneous recovery. Fig. 1 shows that all patientsresponded positively and rapidly to the brief treatment. The pattern of scores suggests that patientsachieved clinically signicant improvements in SPRS ratings of social avoidance, self-conscious-ness, and negative belief. In addition, these gains were maintained at the follow-up assessmentpoints.

Fig. 2 illustrated patients pre- and post-treatment, and follow-up scores on the standardisedmeasures. Pre-treatment scores on these measures fell within the clinical range. The brief treatmentled to clinically signicant improvements in these measures across all patients. Gains were main-tained at follow-up assessments. Both post-treatment and follow-up scores on these measures fellwithin the range for the general population.

The results show that the brief treatment was highly effective in the six cases treated. In thiscase series, mean improvements in FNE and SAD at post-treatment were 13.8 and 12.8, respect-ively. These values translate into improvements of 57.1% and 62.4% in FNE and SAD, respect-ively.

Using self-consciousness ratings as a treatment termination criterion produced a mean of 5.5(range 48) treatment sessions. The decision to use these ratings in order to discontinue treatmentappears to have been highly effective in so much that the treatment effects observed appear tobe as large as those achieved in recent trials of full CT for social phobia (Clark, 1997, 1999),and were maintained at the follow-up assessments.

4. Discussion

The results of this preliminary case series suggest that social phobia can be treated effectivelyand more economically using a brief form of CT based on Clark and Wells (1995) cognitivemodel. Recent theoretical work and empirical evidence as well as clinical experience have allenabled us to extract and rene the active ingredients of CT for social phobia. The results suggestthat CT may be effectively abbreviated by emphasising the modication of attentional and worryprocesses, and targeting negative beliefs using a specic protocol for behavioural experiments.Future randomised and controlled evaluations of brief CT are indicated by the results of this study.

This study has three principal limitations. First, the generalisability of the effects of brief CTis limited by the small number of patients treated. Future studies should aim to evaluate theeffectiveness of this brief form of CT against the extended form and other established effectivetreatments for social phobia so that more reliable conclusions concerning its potency may bereached. Second, the outcome of treatment relied on self-report measures, thus lacking objectiveand independent clinician-administered assessments. Finally, the delivery of brief treatment reliedon only one therapist. The effectiveness as well as feasability of brief CT delivered by less experi-enced cognitive therapists remains to be demonstrated.


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Fig. 1. SPRS ratings of social avoidance, self-consciousness, and negative belief during baseline and treatment, andat follow-up for each patient.


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