The cognitive-behavioural approach is based on the assumption that social phobia is maintained by two factors. The first is a pattern of thinking broadly referred to as faulty self-talk. Faulty self-talk is an illogical and maladaptive style of thinking that serves to persuade us that anxiety-eliciting social situations are more serious or more imminent than they really are. It is treated with cognitive restructuring. The second factor is a lack of opportunity for the socially phobic person to learn that they have nothing to fear, resulting from escape and/or avoidance of anxiety provoking situations. It is treated by giving exposure treatments that involve presenting the person with a hierarchy of progressively more anxiety-eliciting social situations, until distress is extinguished.

Why consider doing cognitive behavioural therapy in a group? There are several advantages to doing therapy in a group compared to doing it individually. First, there is a sense of universality clients get in group from realizing they are not alone in suffering from their problems. Second, the group provides opportunities for vicarious learning from witnessing other people solve similar problems. Third, the client's attendance in group for he first time is like a public declaration of their commitment to change. Other advantages particularly relevant to cognitive behavioural therapy are opportunities for role-play and assistance disputing irrational thoughts. Through role play, realistic yet controlled exposure situations can be tailored to the individual needs of each client. The goal in disputing irrational thoughts is to replace illogical and maladaptive thoughts with more positive and logical ones.

Cognitive behavioural group therapy (CBGT) is a group treatment for social phobia developed by Richard Heimberg at the University of Albany's Centre for Stress and Anxiety Disorders. It is designed to take place in weekly, 2-hour sessions over a 12 week period, and makes use of cognitive restructuring and desensitization (exposure treatment) techniques. A highly structured approach is used to teach these techniques, beginning with an exploration of the link between clients' faulty self-talk or irrational thoughts about social situations, and their anxiety in those situations. Next, clients are given some tools for identifying and disputing their irrational thoughts, and replacing them with healthier ones.

Finally, clients are given imaginal, simulated and actual (real-life) exposures to feared social situations in a graduated progression of experiences known as a desensitization hierarchy. The anxiety provoked by these experiences is countered with cognitive restructuring of the clients' faulty thinking, and an assortment of relaxation techniques. Desensitization is complete when clients' no longer experience significant anxiety when they encounter the feared social situations.

It is important to note that although treatment is given in a group format, individualization takes place on at least two different levels. First, the desensitization hierarchy, and therefore the series of exposure experiences, tends to be unique to each individual client. Similarly, clients are encouraged to develop their own cognitive restructuring routines for use before and after exposure exercises.

Another important feature of CBGT is that little more than half of the active treatment actually takes place in sessions. The rest of the work takes place in the form of between-session homework assignments that involve subjective anxiety ratings, and practice with both cognitive restructuring and desensitization. Sometimes the homework is done on a session-to-session basis, but other times more than the week interval between sessions is required in order for the client to obtain sufficient practice. For example, the self-exposure assignment may be to approach an acquaintance for a date. In these cases, homework is carried over two weeks or more.

In field trials of CBGT (Heimberg, Dodge, Hope, Kennedy, Zollo & Becker, 1990), those receiving the active treatment were found to have significantly lower social anxiety than others who received what they thought was a treatment, but was not. This difference held up after 6 months, and again after an average of 5.5 years. Seventy-five and eighty-one percent of the group receiving CBGT were found to be significantly improved at the end of treatment and after six months, respectively. This compared with forty and forty seven percent of the attention-placebo group.

CBGT at Aegis
CBGT at Aegis Psychological Services follows the 12, two-hour session format described above with two exceptions. First, the sessions will take place on a weekly basis at the beginning, but may be extended to biweekly or even monthly toward the end to suit group members' needs and opportunities for between-session practice. The individual fee per session is $80, or $960 for the entire series. Second, the group sessions are preceded by a two-hour, individual assessment session. The total fee for the two-hour assessment is $320.

The purpose of an assessment session is to determine the appropriateness of CBGT for each client. It consists of an interview, a self-report social anxiety scale, and sometimes personality testing. The self-report social anxiety scale is re-administered at the conclusion of treatment to provide an estimate of treatment effect. Personality testing is usually done to rule out the possibility of a co-existing emotional problem delaying the recovery. People will not ordinarily be accepted into group if they were significantly depressed, if there was a potential for them to be disruptive (e.g., people who mask their anxiety with anger), if their social phobia was so severe they could not tolerate group, or if they had severe deficits in social skills.

In cases where CBGT appears appropriate, the assessment session establishes the precise nature of the client's problem with anxiety, including detailed information about the kinds of social conditions that elicit anxiety and avoidance. Fear, avoidance, and fear of negative evaluation hierarchies are then constructed, and a treatment contract is developed targeting 2 or 3 specific social situations.

Ordinarily the group size ranges from 4 to 7 members. If possible, a balance is achieved with respect to gender, age, and backgrounds, so that every member has at least one other person with whom they can relate. Similar levels of severity of social phobia, and a clear finding of social phobia as the principle diagnosis are also important.

References
      Heimberg, R. G., Dodge, C. S., Hope, D. A., Kennedy, C. R., Zollo, L. & Becker, R. E. (1990). Cognitive-behavioral group treatment of social phobia: Comparison to a credible placebo control. Cognitive Therapy and Research, 14, 1 - 23.