Behaviour Research and Therapy 39 (2001) 713720 www.elsevier.

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Brief cognitive therapy for social phobia: a case series

Adrian Wells
a

a,*

, Costas Papageorgiou

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 treatments for social phobia are cognitive therapy and exposure. However, the degree of improvement across these treatments is variable, and their implementation is costly and time-consuming. This study aimed to conduct a preliminary clinical evaluation of the effectiveness of a brief, new form of cognitive therapy based on a recent cognitive model of social phobia. Six consecutively referred patients with social phobia were treated using established single case series methodology. Brief cognitive therapy was effective with all patients demonstrating clinically signicant improvements in all measures. Treatment gains were maintained at follow-up. The mean number of treatment sessions delivered was 5.5 and improvements compare favourably with previous treatment studies. Brief cognitive therapy for social phobia appears promising and it is potentially cost-effective. Future randomised and controlled evaluations of this brief treatment are warranted. 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 social phobia can persist for a number of years. Even when psychological treatment is available, social phobia can pose complex therapeutic challenges. Evaluations of psychological treatments for social 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 Psychotherapies, Bristol, UK, July 1999. * Corresponding author. Tel.: +44-161-276-5399; fax: +44-161-273-2135. E-mail address: adrian.wells@man.ac.uk (A. Wells).

0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 0 0 ) 0 0 0 3 6 - 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 trials of 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 training alone. Nevertheless, the degree of improvement, particularly cognitive change, across these treatment modalities is variable and their implementation and delivery is both costly and time-consuming. Clark and Wells (1995) argued that psychological treatment for social phobia may be more effective if it is based on a model of the cognitive processes involved in the maintenance of this disorder. In view of this, they proposed a cognitive model highlighting specic cognitions, and maladaptive attentional and coping strategies in the perpetuation of social phobia. In Clark and Wells (1995) cognitive model, it is proposed that individuals with social phobia process negative aspects of themselves on exposure to feared social situations. This self-processing usually occurs as an impression of appearance from an observer perspective, in which symptoms of 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 calamities and controlling or concealing symptoms. The problem with self-processing is that it diverts attention away from processing external social information that could modify negative beliefs. Safety behaviours 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 dangerous. Such behaviours can exacerbate symptoms and contaminate the social situation. Aside from in-situation self-processing, individuals with social phobia are also thought to engage in pre- and post-event worry that maintains negative perceptions of the self. Recent evidence is consistent with 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 is structured as a sequence in which idiosyncratic conceptualisation and socialisation are followed by manipulations of safety behaviours and self-focused attention in feared social situations in conjunction with exposure as a behavioural test of negative self-beliefs. The next step in the sequence involves modifying the content of the distorted observer perspective self-image. Strategies 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 results with mean changes in fear of negative evaluation between 1.5 and 2 times greater than those reported in previous outcome trials of cognitive-behavioural therapy (Clark, 1997). More recently, Clark (1999) reported preliminary data from the Oxford randomised, placebo-controlled trial comparing 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 reducing symptoms 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 to abbreviate this treatment, modications were based on theory (Wells & Matthews, 1994), empirical research supporting treatment components (Harvey, Clark, Ehlers & Rapee, 2000; Wells et al., 1995; Wells & Papageorgiou, 1998, 1999, 2000), and our clinical experience in delivering the 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 case series using an AB design (Barlow & Hersen, 1984) with follow-up was implemented. For this design, all patients were assigned to no-treatment baselines ranging from 3 to 5 weeks. Individual baselines acted as control periods, and were extended until stable trends in most outcome measures were evident. During baseline periods, the therapist met with patients weekly in order to administer and collect relevant outcome measures. The duration of baseline contacts was limited to approximately 10 min, and no treatment or discussion of the content of patients fears was permitted during this time. Following individual baseline intervals, brief CT was delivered weekly, with each treatment session lasting up to 60 min. On completion of treatment, patients were followed up 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 social anxiety/phobia were included in the case series. Referrals were made directly by local family physicians 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 nongeneralised or specic subtype. Diagnoses were made following the administration of the Structured 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). Patients ages ranged from 18 to 44 years, and the duration of social phobia problems ranged from 2 to 27 years. None of the patients had received any previous psychological treatments for social phobia and they were not taking psychotropic medication. 2.3. Measures A comprehensive battery of standardised and widely used self-report measures assessing different dimensions of social phobia were administered. These measures included the following: Fear of 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 ve rating scales assessing key components of the Clark and Wells (1995) cognitive model of social phobia in recent anxiety-provoking social situations. These scales include: distress (08), avoidance (08), self-consciousness (08), frequency of safety-seeking behaviours (08), and negative beliefs (0100). For purposes of brevity, only SPRS avoidance, self-consciousness, and total nega-

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tive beliefs are reported here (the additional data is available on request). All measures were administered at pre- and post-treatment, and 3- and 6-month follow-up assessments. Patients also completed the SPRS scales weekly at the beginning of each baseline week and CT session. 2.4. Procedure The treatment followed that devised by Wells and Clark (1995) and outlined in Wells (1997). However, several modications were made to this protocol to produce a brief form of the intervention. In order to achieve this aim, we relied on both empirical evidence supporting treatment components (Harvey et al., 2000; Wells et al., 1995; Wells & Papageorgiou, 1998, 1999, 2000) and our clinical experience to extract and rene the active components of the CT package. We intended to deliver a minimum number of treatment sessions. Thus, CT was terminated when the patients self-consciousness ratings reached at least 1, and this could not be attributed to increased social avoidance. This criterion was selected as self-focused attention is viewed as a general marker for maladaptive beliefs and processes in emotional disorders (Wells & Matthews, 1994), and it has been linked to the maintenance of anxiety in social phobia (Clark & Wells, 1995). Thus, we aimed to modify not only negative cognitive content but also dysfunctional cognitive processes across the treatment sessions. Brief CT differed from full CT in a number of ways. Particular components of the full treatment version were either augmented, abbreviated or not implemented. There was less use of verbal reattribution strategies, less time spent on reducing safety-seeking behaviours, and no diary keeping of negative thoughts. There was an increased emphasis on modifying excessive self-focus, consisting of instructing patients to be externally focused on other people during feared social situations. Moreover, this procedure incorporated specic instructions to generally increase the intensity of external experiences by monitoring and observing the details of the external environment, and maintaining external attention in a number of situations, not only those involving encounters with feared cues. Detailed instructions to ban and interrupt worry in the form of pre- and post-event thinking were provided in the rst two treatment sessions and there was greater emphasis on this aspect. At least two in vivo behavioural experiments aimed at disconrming negative beliefs and thoughts about anxiety-provoking social situations were implemented in each treatment session. These adhered strictly to the PrepareExposeTestSummarise (P-E-T-S) protocol (Wells, 1997) in order to facilitate optimal cognitive change. For this purpose, experiments were presented in the context of a specic cognitive rationale, and involved brief exposure to anxiety-provoking social situations in conjunction with discrete disconrmatory manoeuvres intended to test patients idiosyncratic negative beliefs. The results of all experiments were summarised in terms of idiosyncratic cognitive conceptualisations of patients social phobia problems. Consistent with full CT, brief CT incorporated video feedback methods which aimed to modify the patients distorted observer perspective (Hackmann, Surawy & Clark, 1998; Wells, Clark & Ahmad, 1998; Wells & Papageorgiou, 1999). All patients were treated by the second author who had appropriate training and experience in CT. For purposes of this case series, training and supervision in CT for social phobia was provided by the rst author. Throughout the case series, the therapist continued to receive weekly individual supervision.

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3. Results Patients SPRS scores on social avoidance, self-consciousness, and total negative belief during baseline and treatment periods, and at follow-up are shown in Fig. 1. The baseline scores on these weekly 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 patients responded positively and rapidly to the brief treatment. The pattern of scores suggests that patients achieved clinically signicant improvements in SPRS ratings of social avoidance, self-consciousness, and negative belief. In addition, these gains were maintained at the follow-up assessment points. Fig. 2 illustrated patients pre- and post-treatment, and follow-up scores on the standardised measures. Pre-treatment scores on these measures fell within the clinical range. The brief treatment led to clinically signicant improvements in these measures across all patients. Gains were maintained at follow-up assessments. Both post-treatment and follow-up scores on these measures fell within the range for the general population. The results show that the brief treatment was highly effective in the six cases treated. In this case series, mean improvements in FNE and SAD at post-treatment were 13.8 and 12.8, respectively. These values translate into improvements of 57.1% and 62.4% in FNE and SAD, respectively. 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 treatment appears to have been highly effective in so much that the treatment effects observed appear to be 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 effectively and more economically using a brief form of CT based on Clark and Wells (1995) cognitive model. Recent theoretical work and empirical evidence as well as clinical experience have all enabled us to extract and rene the active ingredients of CT for social phobia. The results suggest that CT may be effectively abbreviated by emphasising the modication of attentional and worry processes, 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 CT is limited by the small number of patients treated. Future studies should aim to evaluate the effectiveness of this brief form of CT against the extended form and other established effective treatments for social phobia so that more reliable conclusions concerning its potency may be reached. Second, the outcome of treatment relied on self-report measures, thus lacking objective and independent clinician-administered assessments. Finally, the delivery of brief treatment relied on only one therapist. The effectiveness as well as feasability of brief CT delivered by less experienced 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, and at follow-up for each patient.

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Fig. 2.

Scores on standardised measures at pre-treatment, post-treatment, and follow-up for each patient.

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