Cognitive Behavioural Therapy:
Components of Treatment

Cognitive behavioural therapy is the psychotherapy best supported by the research literature as working well with social phobia. Roughly three in four people with social phobia respond to treatment with cognitive behavioural therapy, and treatment effects have been found to last for up to five years.

Cognitive behavioural therapy is actually a combination of therapies meant to address the physical, cognitive and behavioural aspects of anxiety. The physical component involves the management of physical symptoms using a combination of relaxation techniques. These include diaphragmatic breathing, progressive relaxation and guided visualization. The cognitive component is called cognitive restructuring, and the behavioural component is called exposure.

Relaxation techniques are readily available through self-help books (e.g., Bourne, 1995) and tapes, so the remainder of this presentation will focus on cognitive restructuring and exposure.

Cognitive Restructuring
Cognitive restructuring is based on Beck and Emery's (1985) cognitive theory that describes anxiety and other negative emotions as products of faulty thinking. Treatment consists of correcting this faulty or illogical thinking by repeatedly confronting cognitive distortions with discrepant information. This information comes from every day experience, role-playing, and homework assignments. The entire procedure is carried out in four steps described below.

Step 1: Elicit automatic thoughts
Automatic thoughts are habitual ways of thinking. They usually occur spontaneously. When they do not, a couple of techniques may be used to elicit them.

1. Recall by Association

(a) Focus on the other components of anxiety (e.g., physical symptoms, behaviour), and ask for associated thoughts.

(b) Focus on the image of being anxious in a social situation and ask for whatever words come to mind.

2. Backward Reasoning

Ask: What kind of thought might have made you feel that way?

Step 2: Identify underlying irrational beliefs
Examine the automatic thoughts for any cognitive distortions that may be present. These cognitive distortions usually occur as one of any number of unrealistic or irrational beliefs that can be reduced to two basic thinking errors. Errors of probability overestimation reflect our tendency to blow things out of proportion by making unpleasant events seem more likely. Catastrophizing errors do their damage by making unpleasant events seem as though they are unbearable and could go on forever.

Two techniques commonly used to help identify irrational beliefs are the downward arrow technique and the use of thought records to find common themes. The downward arrow technique consists of challenging statements people make about what they think is causing their negative mood states by repeatedly asking the question, "If that were true, why would it be so upsetting?" Thought records are a common form of homework given to people in cognitive behavioural therapy that require them to record their automatic thoughts associated with problem situations (e.g., social avoidances or fears) during the week.

Step 3: Challenge the irrational beliefs
Once the irrational belief underlying an automatic thought has been identified, it is important to refute these beliefs by examining the evidence for them, and by looking for alternative explanations.

Generic questions called "dispute handles" originally developed by Sank and Shaffer (1984) can be used to refute irrational beliefs in two ways. Questions about how certain we are a particular outcome will occur are referred to as probability dispute handles. Questions about the worst thing that could happen, and how bad that is are called coping dispute handles.

Step 4: Replace the irrational beliefs with suitable alternatives
Often the replacements for automatic thoughts become evident in the course of refuting the irrational beliefs on which they are based.

Exposure
Exposure is a behavioural technique based on systematic desensitization, and arguably the most active therapeutic ingredient of cognitive behavioural therapy. It involves experiencing a feared social situation in progressively less controlled and manageable ways. The first is called covert rehearsal. It involves imagining the social interaction as vividly and in as much detail as possible. The second is to role play the social interaction with a therapist or fellow clients, and the third is to encounter the actual social situation, in-vivo.

Covert rehearsal and role-playing are usually done in session. In-vivo exposure is done out of session as part of homework assignments, along with reading, keeping thought records, and practicing relaxation techniques. Exposure is usually done in a progressive manner (the "other" progression), starting with the least troublesome situation from a fear and avoidance hierarchy.

Covert rehearsal and role-playing have the advantage of allowing the client to perform under controlled conditions, carefully set up to simulate the real-life, feared social situation.

The goal of exposure is to have the client engage the feared social situation long enough for his/her anxiety to habituate.

Rule of thumb is to strive for a 50 percent decline in SUDS or SUDS below 30, whichever comes first, and to stop exposures when initial SUDS is below 30.

Research Findings
The following are results from a outcome study of 19 participants in three groups of cognitive behavioural therapy for social phobia from September 1996 to April 1999. There were eleven men and eight women ranging in age from 21 to 77. They all completed a 12-week program developed by Richard Heimberg (1991) at the University of Albany's Centre for Stress and Anxiety Disorders. Following their completion of this program, we measured their level of satisfaction using the following survey.

Satisfaction survey results

One of the advantages of working with people who have Social Phobia is that they are very agreeable and eager to please. A disadvantage of working with people who have Social Phobia is that they are very agreeable and eager to please. Consequently, we felt it necessary to obtain slightly more objective information about their anxiety symptoms. We did this by administering the Social Phobia and Anxiety Inventory (SPAI) before and after the program.

SPAI results

*T-test significant p<.001

The mean SPAI score dropped more than 30 points and two categories from probable social phobia to possible mild social phobia.

References
      Beck, A. T. and Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books

     Bourne, E. J. (1995). The anxiety and phobia workbook. Oakland, CA: New Harbinger Publications.

     Heimberg, R. G. (1991). A manual for conducting cognitive-behavioral group therapy for social phobia (2nd ed.). Unpublished manuscript, State University of New York at Albany.

     Sank, L. I. and Shaffer, C. S. (1984). A therapist's manual for cognitive behavior therapy in groups. New York: Plenum Press.