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Sunday, January 29, 2012

Cognitive Behavioural Group Therapy for Social Phobia by Heimbery and Becker


Cognitive Behavioural Group Therapy for Social Phobia 
Contents
Understanding the Nature of Social Phobia. 2
1.      The Diagnosis and Etiology of Social Phobia. 2
Criteria. 2
Demographics. 3
Feared Situations. 3
Etiology. 3
2.      Subtypes of Social Phobia, Comorbidity, and Impairment. 4
Personal Characteristics. 4
3.      Cognitive Functions in Social Phobia. 4
4.      Dysfunctional Cognitive Process in Social Phobia. 5
5.      A Cognitive Behavioural Formulation of Social Phobia. 6
6.      Assessment of Social Phobia. 8
Cognitive Behavioural Group Therapy for social phobia: a treatment manual 9
7.      An Overview of Cognitive Behavioural Group Therapy for Social Phobia. 9
8.      The Treatment Orientation Interview.. 9
9.      Session 1. 13
Introductions. 13
Ground Rules. 13
Client work. 13
Problem Presentation.: 13
Presentation of Cognitive behavioural model of Social Phobia. 13
Introduce Anxiety. 14
Relate thoughts, sensations and behaviour. 15
Discussion of components of anxiety. 16
Introduction to automatic thoughts. 16
Eliciting Automatic thoughts regarding group treatment. 16
Homework Assignment. 17
10.         Session 2. 17
Homework review.. 17
Identification of thinking errors in AT’s: 17
Thinking errors. 17
Disputing Automatic Thoughts and developing rational responses. 20
Homework assignment for Session 2: Cognitive Restructuring. 21
Preparation for Initiation of In session exposures. 21
11.         In Session Exposures. 22
Rationale for in session exposure. 22
Preparation for an in session exposure. 22
12.         Integrating Cognitive restructuring procedures with in session exposures. 24
Before an In session exposure. 24
In Session Exposure steps. 25
Identification of thinking errors in recalled thoughts. 25
The process of disputation of AT’s and the production of a rational response. 26
Common Automatic Thoughts. 26
During an In-Session Exposure: SUDS Ratings and Rational responses. 28
After an in session exposure: the cognitive debrief. 28
13.         Homework Procedures. 32
14.         Session 3-12 Putting It All together and troubleshooting cognitive behavioural group therapy  33
Timing issues. 33
Session 12. 33
Termination Issues. 33
Additional Sessions. 33
Trouble shooting. 34
Homework assignments gone awry. 34
Summary. 35


Understanding the Nature of Social Phobia

1.     The Diagnosis and Etiology of Social Phobia


Criteria

Social phobia was first diagnosed in DSM 3 in 1987
Diagnostic Criteria
1.       A persistent fear of social or performance situations where one is  exposed to unfamiliar people or to scrutiny
2.       Exposure to situation produces anxiety
3.       Client sees their reactions as an irrational and excessive
4.       The avoidance of these situations significantly impacts on a person’s life
Social phobia is an extension an extremity on a continuum which encompasses all the evaluation anxieties that accompany social interaction, test taking, public speaking going to a party etc.
On one end of the spectrum is someone who doesn’t actually register anything about the other, which I suppose would be autism, then people who don’t care at all who are egotists, then it comes through sensitive people, shy people, contextually social phobic to full blown on the other sides, well that’s quite a journey

Demographics

Prevalence of social phobia in the population is hard to tell, but studies show that there is an 11% per lifetime occurrence in men and 15% in women. Social phobia is found slightly more frequently in women than in men.

Feared Situations

Priority order of feared situation in the community at large
1.       Public speaking
2.       Social Gatherings
3.       Eating in public
4.       Using a public toilet
People with social phobia have the following feared situations
1.       Being introduced
2.       Meeting people in authority
3.       Using the telephone
4.       Having visitors come to one’s home
5.       Being watched doing something
6.       Being teased
7.       Eating at home with acquaintances
8.       Eating at home with family
9.       Writing in front of others
10.   Speaking in public

Etiology

Clients tend to have relatives with social phobia so there seems like there is a genetic component, however there’s also an environmental component in child rearing, but it’s complicated (no shit). Social phobia does appear to run in families and having a parent with social phobia is the best predictor of social phobia.
Genetics and environmental factors both appear to make a contribution to the cause of social phobia but most likely it is not directly transmitted but rather learns a disposition to respond with anxiety in certain situations, this is most likely to be a behavioural inhibition to the unfamiliar. So you can classify small children as behaviourally inhibited i.e. retreat from the novel, or uninhibited, approach to the novel. This trait extended into later life and was highly correlated with social phobia.

2.     Subtypes of Social Phobia, Comorbidity, and Impairment

Subtypes of social phobia are generalised social phobia, when the phobia extends across a wide variety of social interactions. 
There is an overlap between avoidant personality disorder and social phobia. APD is described as a pervasive pattern of social discomfort, which is very similar to a generalised social phobia, fear of negative evaluation and timidity.
Co-morbid disorders with social phobia are
1.       Panic attacks
2.       Agoraphobia
3.       Generalised anxiety disorder
4.       Alcoholism

Personal Characteristics

Most onset between 13 to 24, other major areas are 0-5 and 11-15. Social phobia typically occurs later than the onset of small animal phobias but earlier than the onset of panic disorder or agoraphobia. Episodes tend to run a chronic course, and can last on average 19 years. Mean age for presentation is around 30. Social phobia seems to be treated later than say panic attacks as it hasn’t got very good press and people don’t think it’s curable like they do with panic attacks.
Social phobics have trouble with their
1.       Relationships
2.       Education
3.       Employment and career functioning

3.     Cognitive Functions in Social Phobia

Social Phobia is often marked, well invariably marked by cognitive dysfunction towards self and others. There are three aspects of this dysfunction
1.       Negative content of thought
2.       Errors of judgement
3.       Dysfunctions of cognitive process
The States of mind theory (SOM) dictates that a .62 ratio between negative and positive thoughts is useful so that you have some realistic caution and some optimism. Social phobics are under this, although only in social situations or in anticipation of social situations. Social Phobics have strong anticipatory anxiety that leads to avoidance of social situations but actually their anxiety decreases if they are involved in social situations.  This anticipatory anxiety focus around how bad I’m going to be, screw up, make a fool of myself, i.e. negative self-evaluation.
Their causal model of social interaction is if something goes badly it’s my fault, if something goes well it’s because of an external factor, the other person, the situation etc.
Social phobics most feared situations are novel ones and ones where there are some high status people.  People with social phobia seeing the powerful other as controlling an orderly world. This is quite different from other sorts of anxiety, say panic attacks for instance, where there is standardly no order and panic attacks happen for no reason. In both instances there is a feeling of not having the resources to deal with the powerful other or the unordered world.
Social phobics see a higher probability of social disaster and a higher believe in the awfulness of an event than does a control group, err no shit…
Social phobics do have deficits in social skills, you know eye contact, listening etc., but think the impact of them on their ability. Social phobics also remember social events as worse than they actually were in comparison to a control group.
Social phobics are generally more perfectionist than control groups. They have high internal standards and they also attribute higher standards to others, than others actually do have. Indeed if they have success with the other, then they think the others requirements for their level of performance actually increases.  Social phobics are very self and not self-focussed.

4.     Dysfunctional Cognitive Process in Social Phobia

Beck claims that schemata work by providing attentional bias towards schema congruent perception.  Anxious people have threatening schemata in consciousness.  There are also theories from Bower about how emotional memory is stored in interconnected nodes, so when you have one emotion, then you have access to all the connected nodes to it.
Social phobics have a schema of Social threat continually activated. Through doing Stroop tests, i.e. write a word in a colour and see if that words affects how quickly they can record the colour, then that showed that when a social event is possible then the social threat schemata is activated. It is also shown that after that threat is activated a complex avoidance mechanism is also activated.
Social phobics also show an increase level of memory of threats The other aspect of memory is can a social phobic remember in a social situation, then can they remember any fact in a socially phobic situation, naturally you’d think not as they are too busy processing information about themselves, however this isn’t the case, and sure you see a deterioration of recall but it’s not off the scale.
When a socially phobic person doesn’t get the type of interaction they want with another then their perception turns back onto themselves, to effectively see what it is about them that caused this to go wrong. This is done in terms of an image, so images are as important as cognitive self-statements.
Images with social phobics tend to be from the observer perspective. So the observer perspective is being seen as something, the field perspective is feeling that you are so the image is looking from your eyes, as opposed to on you from god’s eyes perspective.
When a social phobic perceives they haven’t made the impression they want on someone then their attention shifts to themselves and begin self-observation and monitoring. This impacts on how they are seen to the other. So when a social phobic doesn’t have the interaction they want then they see themselves in terms of an image to the other, and then they subject themselves to a cognitive and affective scrutiny, it’s almost their feared impact of the all-powerful other that they are scared about but this time they are doing it..
If a social phobic gives an image in a social phobia situation it is always from the observer perspective which is different to the control group, but in other situations where they are just anxious it’s from the field perspective.
The field perspective is usually to do with the looking at properties of the situation, whereas the observer perspective is usually to do with the looking at the properties’ of the person.
For social phobics as their anxiety increases in a social situation then there attention becomes more internal, stable and global, whereas for the control group the opposite is the case.

5.     A Cognitive Behavioural Formulation of Social Phobia

A child may have a natural tendency with be withdrawn, if you couple this with a parent who is over protective then it can result in anxious children, conceivably socially phobic children. Childhood teasing can be associated with depression and anxiety in adult life. When you are taught you can’t do something both by modelling and cognitively, and you see people who can do it, then you are going to start incessantly comparing.
Social Phobia:
1.       Perceive audience as negative evaluators
2.       View self objectively in the same way as the negative evaluators
3.       Define  standard of evaluators
4.       Compare self with standards and come up short
5.       Produce Anxiety
a.       Cognitions
b.      Affect
c.       Behaviour
6.       Symptoms of anxiety both damage performance and are used as evidence of coming up short, so cycle maintains
The perceived audience, who are perceived as negative evaluators may not actually be watching, or evaluating negatively, they are rather just judged as being so.
Once the audience has been selected the client judges themselves through their eyes, the image that they see, the thoughts and feelings that they have.  The image that the other person has of you is threatening, and therefore takes on more importance than your own view of yourself. It should also be noted that the image of self that the client has constructed and then believes the other thinks is one constructed by a social anxious individual. This image is both constructed on what is feared and also in terms of past performance, the only way to find out how you appear is to ask, and then that’s just that person’s opinion, the bitch is there’s no objective truth.
The client’s attention is directed three ways. One there is the vigorous scanning of the audience for any indications of negative evaluations. Secondly there is the scanning of self for any behaviours that could warrant negative evaluations. Finally there is the social interaction at hand. On a purely pragmatic level you cannot have a social interaction when you are checking their evaluations and your performance.
Social phobics set the standards that the audience has for them, the more attractive the audience then conceivably the higher the standard the audience sets.
The cost of negative evaluation is high, the outcome dreadful, the unbearable shame.  When the social phobic sees his audience he believes from all his past experience, that they are representative of this, so if he meets a woman that he finds attractive then his past failures will be presumed to happen with her, so rather than seeing what happens, he projects onto her certain rejection as this is what has happened before.
When in social situations a social phobic will have cognitive symptoms of anxiety
1.       I’m such a loser
2.       Here we go again
They will have behavioural symptoms of social anxiety
1.        Wanting to leave the social situation.
2.       Avoiding eye contact
Physical symptoms of social anxiety
1.       Blushing
2.       Sweating
3.       Muscle twitching
Social phobics generally tend to exaggerate how bad these are, and also how important their audience holds them.
Perceived internal cues
These feed back into the social phobic’s perception of their objective self

The vicious cycles of social phobia, are the evaluation of self, providing evidence that things aren’t working, which provides more symptoms of anxiety, of negative thoughts, of beating heart etc., which again provides more evidence that this is a bad social interaction, which then increases the level of discomfort, until the level of discomfort becomes unbearable.  Social feedback is often indirect and ambiguous, which is fuel to the fire of the social phobic with a leaning towards interpreting social events as social threat, social negative evaluation.  After the social situation the social phobic, recalls the engagement standardly from the observer point of view, and whilst under the guise of learning from the experience, repeatedly beats themselves up.

Effective treatment for social phobia should include the following:
1.       Negative beliefs about social situation
2.       Negative beliefs about self
3.       Negative predictions about the outcomes of social situations
4.       Anticipatory anxiety
5.       Attentional focus on social threat cues
6.       Avoidance of feared situations
7.       Negative evaluation of performance after the situation has passed


6.     Assessment of Social Phobia

Assessment is needed to tell what to target in group work. You can often find that people might have evaluation phobia, without interaction and vice versa. When you are setting up a group it is better to not get all of one type together as otherwise their won’t be the opportunity in the early stages of supporting each other. It is true that fear of social interaction and social phobia are often seen together, this isn’t always the case
The questionnaires used are:
1.       Social Interaction anxiety scale (SIAS)
a.       Looks at the fear of interaction
2.       Social phobia scale (SPS)
a.       Looks at the fear of being observed and judged
Both questionnaires are short, and easily administered.
Both of these questionnaires have appeared reasonable predictors of the severity of social anxiety. This can be useful to see how the client may well interact or struggle with some of the assignments and is obviously a useful benchmark in terms of progress, pre and post treatment.
The Social Phobia and Anxiety index (SPAI) is a highly validated measure and assesses somatic cognitive and behavioural responses to a variety of interactions. Whilst it collects a large amount of information and can be useful in treatment planning it can take time to administer.
Social Phobia Inventory (SPIN) is increasingly used alongside pharmacotherapy.
Liebowitz Social Anxiety Scale, this is the most frequently administered test. This evaluates fear, avoidance, social interaction and performances situations using a 4 point Likert type scale. It contains four subscales: Fear of performances, fear of social interaction, avoidance of social interaction, avoidance of performance.
Thought listing: It is important to get clients to list their anticipatory anxiety thoughts. Creating this list will show the areas that need to be targeted cognitively, they can I guess help explain behaviour within a social situation where the cognitions might not be so obvious due to high emotion and behaviour.
Stroop tests, test the speed of processing and use a word within a colour, so first of all they use a different word to the colour, then they use hot words to see how cognition is impacted by certain conceptual groups.
Behavioural assessment tests BATS also deserve a mention where a specific situation is set up to analyse a client’s response. This can also be repeated against other clients so that you can compare clients responses and better understand clients I guess, although this just seems a test for the sake of it, so what if you see one person struggling in a test and another not so.  There are two ways to work with a BAT that is at the molecular or molar level. The former dives into the detail that enables the purpose, so for public speaking did they hold eye contact. Molar however concerns itself with purpose and so with public speaking then did they hold their audience.

Cognitive Behavioural Group Therapy for social phobia: a treatment manual

7.     An Overview of Cognitive Behavioural Group Therapy for Social Phobia

Cognitive Behavioural Group Therapy, CBGT, aims to break the vicious cycle of social anxiety through cognitive restructuring and exposure. There is a virtuous circle that is aimed at, the less fear there is of the catastrophe of social problems, then the less the attention needs to scan the other and self for signs of impending disaster. The less this is the case then the more resources become available for effective communication. The exposure happens in session and then in vivo as part of a homework assignment.
Exposure works through breaking into the avoidance pattern which will show that the feelings of anxiety will subside. ~Whilst avoidance is happening this prevents the underlying fears that the anxiety is unmanageable being challenged. Secondly exposure allows the client to practice the actual skills they need in that situation, so it’s not just a question of talking about it, but rather it’s a case of actually doing something about it. Exposure also allows the ability to test dysfunctional beliefs, I couldn’t cope with x, then exposure to x finds out whether or not that is the case.
Exposure breaks the maintaining aspect of avoidance, it also allows cognitive restructuring through challenging the underlying beliefs. To challenge a belief, then ask does it makes sense, is it useful, is there a better way of thinking about this.
If the dysfunctional beliefs that are used to create anticipatory anxiety can be challenged through exposure, then reducing the amount of anticipatory anxiety again makes the interaction that much easier. The more the dysfunctional beliefs and anxiety can be reduced the more ability there is for the client to experience the natural positive reinforcement of other people.


8.     The Treatment Orientation Interview

The treatment orientation interview
In this interview then you need to assess the suitability of the client for group work. You need to introduce the client to SUDS,  AT, and you need to get the client to generate a fear and avoidance hierarchy.  The understanding that CBGT has of social phobia is then described and the ways of treating are explained i.e. exposure and cognitive restructuring.
Social phobia\social interaction anxiety. Here there is a fear of either being judged negatively or shamed or rejected by a social group. In both instances there is a high fear of the impact of such action and a feeling that you cannot cope with the outcome. On the basis of this, the all-powerful other becomes the person who is perceived to look at you and judge you. On the basis of these beliefs then the social phobic has anticipatory anxiety before a social interaction and may well avoid it on the basis of this, should he venture past this anticipatory anxiety then in a social interaction he gives the evaluator a standard by which they judge him, this standard will change on the basis of context. He will then observe himself through the eyes of the all-powerful other and scan himself for signs of inefficient performance that would incur the wrath of the all-powerful other. The act of scanning self and other takes quite a bit of his attention away. He also finds his memory drawn to times of social failure; he scans the environment for hint of social failure. Thus most of his energy is spent in defending himself against possible attack. Taking all his energy away then he naturally can’t engage very well with the other person and can experience social rejection or performance lapse but the irony here is that it is because it is so important for him for it not to happen that it does. The dysfunctional thoughts about how he can never have a successful relationship create the feeling of fear and anxiety and enable his beliefs to become true, so thoughts affecting emotions.
Sessions 1 and 2
1.       Prepare and discuss the CBT model of social phobia and the rationale for CBT treatment
2.       Training in cognitive restructuring, so show Thought record work sheet, show the challenging beliefs question set
3.       Assign a diary to keep track of automatic thoughts
Sessions 3-11
This is where specific exposure tasks and cognitive restructuring takes place

Session 12
Review work and see what situations might still be problematic.

Setting up the group
Qualities of therapist
1.       Reasonably socially relaxed must be able to model the skills
2.       Know basic principles of group dynamics
3.       Know social phobia
Best to have 2 therapists and 6 clients. 2 Therapists means that one can look after the group the other the individuals. One can look after an exercise the other can monitor the impact on other members of the group. It’s best to have one man and one woman. Likewise with the group best to have a mix of the sexes and to ensure you have at least 2 of each sex.
Group sessions are conducted for between 12-24 weeks, each session being 2.5 hours in length. There must be a week between sessions so the clients get a chance to practice their skills. When setting up the group room it is imperative that there should be comfortable chairs and a comfortable temperature. Personal space that is afforded by the amount of people in the room is important as if there is infringement this could cause significant anxiety, likewise temperature is of concern as social phobics may be very worried about sweating or blushing or having any other heat reaction. It’s also important to have a white board, or something where by what has been learnt by clients can be put on the wall. The rationale here is that when feeling anxious during exposure their cognitive faculties will reduce and they will forget how to cognitively restructure or how sitting with the emotion will see it subside.
The treatment orientation interview
Purpose
1.       Feedback findings from initial assessments
2.       Complete the individual fear and avoidance hierarchy
3.       Isolate targets to be worked upon
4.       Familiarise the client with CBT techniques of exposure, and cognitive restructuring
5.       Familiarise the client with the group and its requirements, e.g. homework
6.       Address any fears that arise about working in a group
During the treatment orientation interview then there is also a screening that is going on here.
If a client’s anxiety is so high it’s going to be disruptive to the group, then no they can’t come in
Severe depression might rule someone out as they will get stuck in their depressive cycles and not be able to do homework and conceivably contribute in group. If a client has another diagnosis then if the other diagnosis is more severe then it should be worked on first. If the client relies on anti-anxiety drugs that’s fine but they must be stable and not take more to manage doing group work, likewise they can’t be so monged out can’t achieve the required anxiety in exposure. The same is true for meds as alcohol. Alcohol is a drug of choice for the social phobic, so ensuring they don’t drink to come to do group work and don’t drink during is vital, as this would be maintaining safety behaviour.
You need to find out about a client’s social anxiety in some detail, so you need the following information for socially anxious situations
1.       Describe the anxiety response in 5 aspects
2.       Describe antecedents to anxiety response
3.       Look at situational modulators
Getting the previous information should generate a list of situations that cause problems, of what makes those situations better or worse.
On the basis of this then you can create an individualised fear and avoidance hierarchy. This provides a graded task hierarchy and some structure for the work and a reference point back to success as this will be the bench mark of social phobia. Check out with each item on the list whether or not the client wants to work with it or not, they might not  but always worth checking out about it, so a conscious decision rather than just avoidance can make the decision.
Suds, this needs to be explained and objectified so that 0 is absolutely no anxiety and 100 is the worst possible imaginable, so get them to think of various  items on the scale to test it out this will make sense of it.
The Treatment Orientation Interview aims to instil hope, it’s worked before and 80% of people have reduced their symptoms. 
There are two main fears that clients have :
1.       Exposing their weakness and being the centre of attention
2.       Exposing themselves to their fear

Advantages of Group
1.       Normalises feelings
2.       Peer learning
3.       Learn through helping others
4.       Public commitments
Ground rules for group
1.       Anti-avoidance
a.       Attend
b.      Do homework
2.       Confidential
3.       Help others
Way to get most out of group
1.       Invest energy and effort
2.       Do exercises carefully and practice
3.       Be kind to yourself
4.       Try new ways of dealing with social anxiety



9.     Session 1

Introductions

Starts with Introductions. Encourage people to say as much or as little as they want, but we would encourage you to at least say something which isn’t about anxiety, so we can get to know you. . Get therapists to introduce themselves first, then  allow anyone who wants to speak to do so, really try to avoid going around in a circle to do this otherwise there might be high levels of anticipatory anxiety felt by the person at the end.

Ground Rules

Attendance is really useful, if you can’t make it then phone.
Promptness, if people are late you might feel angry at them due to the lack of respect for fellow delegates. However if you are going to be late, don’t let this stop you coming, just phone ahead to let us know.
Homework Assignments: Critical that you follow through on your homework. If you think that the home
Confidentiality: This means that what is talked about in the group must remain private and confidential. You can talk to people outside the group about what happens, but you must never use anyone’s names or any identifying features about them, what they say is private within the group

Client work

Problem Presentation.: Therapists asks clients in a different order to how they introduced themselves to say a little about what brought them to group and what their hopes and fears are. Therapists should help people if they get stuck here, as this might be the first time they have spoken about their problems and themselves like this publically. If the client gets stuck then the following prompt questions might help:
1.       What is your greatest fear or the situation that causes you most concern
2.       What happens to you when you think about your feared situation(anticipatory anxiety)
3.       What  happens to you when you are actually in that feared situation
4.        What physical symptoms do you get in your feared situation
5.       What do you feel like after the situation has ended
6.       What would you like to do that anxiety prevents you from doing
The aim of the problem presentation is twofold, Firstly to get the clients to speak about their problems, which will have something of an exposure effect. The second aspect and more significant is the normalising effect. To enhance this, then the therapist should look to show similarities between the client’s fears, the situations, the behaviours and the cognitions.

Presentation of Cognitive behavioural model of Social Phobia

Ask clients to define social phobia., what it is and what causes it.
Say:Scientists say that there is no social phobia gene and less than a third of cases is genetically determined and mostly it is learned behaviour, i.e. as we have learnt to be socially phobic as a result of our experiences.
Write on board: Social phobia is a learned response, so we can learn new ways
Ask the clients to think back over their experiences to what they have learned about the social events they have difficulty, with and generate a list of beliefs. Once the list is generated then tell them how other people seem to cope ok with social situations, this being the case then are there any other beliefs that you have when you consider this. Now we have a list of negative beliefs
Ask the clients to imagine one of their situations that they are afraid of, choose one of the beliefs they have written on the board and think if it was true, how would the event turn out and how would they feel. .
Therefore believing these beliefs is having a negative outcome on the future, it is affecting you emotionally and behaviourally, how you feel and how you act.

Introduce Anxiety

There are three components of anxiety
1.       Thoughts
2.       Physical sensation
3.       Behaviours
Investigate each in turn.

Cognition

Ask the clients when they are anxious what thoughts go through their mind, make a list, add to this list by making an example of going to a party, where you say someone important to you and you want to go up and talk to them, and you feel anxious, what goes through your mind.
When these thoughts came did you question them or accept them, and if the latter what effect did they have on you.

Introduce automatic thoughts

What these thoughts are an example of is automatic thoughts. There are different types of thought, some thoughts we have are slow and happen once in a while, say when you think, of what you are going to have for tea. Other thoughts happen very quickly. So if you see someone on the street you don’t like then you might move to the other pavement without ever realising that you have thought, I don’t like that person. Automatic thoughts happen quickly for a variety of reasons, it can be because we have thought them so often, they are a habit and we don’t pay attention to them, such as thinking I must look both ways when crossing the road, or because we need to act quickly, so if a cup is going to slip off the table, you just reach out to stop it, rather than be aware of thinking, there’s a cup falling off the table, which will break and make a mess and then I will have to clear it up.
Some of these thoughts can be negative, and some of them can be incorrect. So as we work with social phobia  we will be looking to see what the thoughts are that happen, and we will hold them up for some investigation to see if they are true or not.  This process is called cognitive restructuring which is a bit of a mouthful but really just means changing our beliefs.

Do the exercise of walking up to an important person, but this time imagine that you are the important person and someone who is nervous is walking up to you, what are you thinking.

Physiology

What does your body feel like when you get anxious, list these on the wall. These symptoms of heart pounding, muscles tensing are getting ready to respond to danger by flight, fight or freeze. Explain these terms, but these are related to physical danger, but social situations are not physically dangerous. We have learnt that these situations are dangerous from our experiences but they are not.. In a physically threatening situation you have something to do with the anxiety, you can fight or flight, but in a social situation then you have nothing to do with this energy. What might happen to your physical symptoms if you didn’t think the situation was dangerous?

Behavioural

Anxiety can disrupt your behaviour, it can make you stammer or laugh a lot. One more harmful behaviour is that it makes you avoid that which makes you anxious. This avoidance can mean avoiding going to a situation that makes you anxious, or going there and drinking a lot, or staying in the corner so as not to interact with anyone, or not looking at people when they talk to you. What all these things have in common is that the situation which makes you anxious is avoided.
What do you think are the harmful effects of avoidance?
The list should include
1.       Avoidance reduces anxiety but
a.       Keeps you from getting what you want
b.      Keeps you from being about to overcome what you are afraid of
c.       Reduces your confidence that you can manage your fear
d.      Makes you feel that you can’t cope

Relate thoughts, sensations and behaviour

Imagine you are sitting waiting for an interview in an office waiting for the interviewer to call you in
What are you thinking?
What are you feeling?
How are you behaving?
How does what you are thinking affect what you are feeling, how does what you are feeling affect how you are behaving, after you have behaved then how does this affect your thoughts and feelings.

Discussion of components of anxiety

Each of these components play a significant part in affecting anxiety, so we must have a technique to use with each of them, these are the techniques that we will use throughout this course:
1.       Thoughts
a.       We use cognitive restructuring
                                                               i.      This will challenge beliefs, we will treat beliefs like experiments and hold them up to inspection.
2.       Behaviour and physiology
a.       Exposure techniques. Through exposing to the fear, then the body’s natural reaction will be to hold fear for a short period and then let it subside. The more this is done the more we are said to get habituated to the fear, we get used to it, and then the feeling of fear goes away, and it stops either needing to avoid the situation or have any danger physiological reaction.
We also need you to do homework assignments which may involved you doing things in real life, through doing the homework assignments daily will enable you to conquer your fears and deal with the anxiety that has been troubling you.

Introduction to automatic thoughts

Therapist should describe a situation that had happened to them and what the automatic thoughts were that occurred to them and what the emotional reaction was. Get the clients to generate different ways of thinking that challenge the automatic thoughts. If you get stuck about generating alternative thoughts, then think about these questions:
1.       what an observer would think about it
2.       What the evidence to support your thought is
3.       What the evidence against your thought is
4.       Is there an alternative explanation
 Think about what the emotional outcome would be if the alternative thoughts were held. Show that it is not event s that create emotions and behaviours, but rather events, are interpreted and these interpretations create emotions. Therefore if we can change our thoughts we can change our emotions and behaviours. As you work through this, generate the AT’s the automatic thoughts and the RR’s, the rational responses.

Eliciting Automatic thoughts regarding group treatment

Generate a list of NATS about group treatment, then generate rational responses to these. Doing this can enable you to work through any blocks that the clients have to group treatment.

Homework Assignment

Monitoring and recording automatic thoughts
Collect a sample of AT’s that happen to them in their lives, the best ones to pick up are the ones when you are feeling anxious, as anxiety is a feeling that comes when we need to pay close attention to ourselves., Recording AT’s means recording the situation, the thoughts and the  feelings, clients should bring in 5-10 AT’s. If a client is sufficiently avoidant to not have any anxiety during the first four days, then they should set aside 15 minutes and imagine items on their feared hierarchy list to feel anxiety, then write the thoughts down that occur to them after that.

10. Session 2

Homework review

Clients should be asked to produce 12 to 15 of their AT’s and to put a brief description of the situation that elicited them.  Every member should put up at least one. If there is any difficulty doing this then you could remember the exercise in session 1 where you  looked at your thoughts about group therapy.  When the 12 have been collected then the therapist should look for similarities between the AT’s and maybe highlight some themes, or some central AT’s as these may be important for the group.  So we have now produced a list of AT’s.

Identification of thinking errors in AT’s:

The list of thinking errors should be handed out
1.       All or nothing thinking
2.       Negative predictions
a.       Fortune telling
b.      Catastrophising
3.       Overgeneralisation
4.       Mental filter (selective abstraction)
5.       Labelling
6.       Mind reading
7.       Discounting the positive
8.       Should and must statements
9.       Emotional reasoning
There is a lot to explain here, so it may be wise to have a break between doing all of them. For each item in the list, then you need to explain it, and give an example. Then you need to ask the clients why they think it’s a thinking error. Then get them to give an example of their own.
To start this session you need to explain thinking errors

Thinking errors

The way that we get our beliefs is in a variety of ways, we can be told them by others, like our parents, we can have certain experiences and learn them, or we can be influenced by those around us. Some beliefs are so old that they become like looking through a pair of glasses, we don’t even realise that we have them on and we don’t think about them. Some times when this happens the beliefs may no longer represent the world as we see it, and we can describe them as thinking errors, which if we held them up to the light, we would see they are not correct.  Thinking errors can often cause emotional distress as we see clients with distress often having a thinking error behind them.  So what we are going to do this afternoon is to go through

All or Nothing thinking

Here the world is split into 2 categories, one which has a positive valence and one which has a negative valence. Standardly the positive category is very small and the negative one is very large. So for example, there are either beautiful or ugly people, and to be a beautiful person then you have to be a super model. You can also see all or nothing thinking when people use absolute words such as always, never, perfect, all so If you say, men are all bastards, then this is all or nothing thinking where there are good guys and bad guys and men are all bad guys.  The effect of all or nothing thinking is a creation of anxiety in clients and affecting their motivation. If the world is full of beautiful or ugly people and beautiful people get dates, if you think you’re ugly then you think you are never going to get a date, and if you are in that situation then you are going to get very anxious as you know that it’s going to go wrong.  If a client has either something is perfect or it is a failure, then again they may not attempt to do things that they can’t do perfectly.

Fortune telling

This error is predicting the future, usually a negative outcome with no good reason.  The trouble with this is that it prevents a person from trying if they think it’s going to be a negative outcome.  One useful way of introducing this is to ask, who can predict the future, which of you has made a fortune on the stock markets.

Catastrophising

To catastrophise is to see an extreme negative outcome, e.g. the plane is going to crash.  Catastrophising again is fortune telling, the effects of it are that it creates anxiety and it prevents you trying things as you think catastrophe will ensue.

Disqualifying the positive

This error rejects any positive experience, any compliments and the like.  If something good happens it isn’t because of me, if something bad happens it is my fault.  The effect of this thinking error is a restriction in the feelings of self-esteem and personal efficacy which in turn prevents clients from having the confidence to follow their desires or dreams.

Emotional Reasoning

This is where you believe something is the case because you feel it, thus I feel foolish therefore I must be foolish, I feel nervous therefore other people must be thinking bad things about me.  People also do this the other way confusing thoughts for feelings, I feel so stupid therefore I must be stupid. The problems that this cause is anxiety,  problems with motivation, and therefore depression.

Labelling

This is summarising ones feelings about oneself or another in terms of a simple negative label.  An effect of labelling means that it says something about someone’s character, which in turn means something that can’t be changed that easily.  It can also distance you from other people if you label them it prevents the relationship developing.  Labelling also prevents you from understanding something better, as if you call something stupid, then you’re thinking stops.

Mental filter

In a mental filter a person focusses on one usually negative aspect of a situation and loses the bigger picture.  The problem with this is that it restricts the development of self-esteem and can therefore lead to depression, it can also create anxiety and depression through a focussing on the negative.

Mind Reading

This is where you know what someone else is thinking without ever asking them. The problems that this can create is in communication and relationship as you can respond to what you think another is thinking when that isn’t the case at all.

Overgeneralisation

Here the client has one negative outcome and overgeneralises it thinking it will always be the case.  This often happens with what has happened in the past. The difficulty with this is that it restricts action and therefore can lead to depression, it can also increase anxiety, if one bad thing happened then many bad things will happen.  Again there is a tendency here to make your worst predictions comes true.

Should and must statements

There are absolute rules about the way life should be run, they can cause feelings of depression when you don’t achieve them, feelings of anxiety to achieve them, they also do not respond to how the world is and how it changes and how you do so again they can appear sterile and non-vital  goals. They can be absolute, perfectionist’s statements that are impossible to live up to and therefore create depression when you don’t.  Again because these are self-goals, attention is focussed purely on self rather than on others and it becomes hard to build relationships.
If should statements are directed at others then it can result in anger when they fail to respond in a way that they should.

Maladaptive Thoughts

A maladaptive thought is one that fails the following test
1.       Does it help my mood
2.       Does the thought help me think productively about the situation
3.       Does the thought help me to behave appropriately
4.       Does the thought reinforce my irrational beliefs
A thought should only be classified as maladaptive it if doesn’t fit any of the thinking errors categorisations. The problem with maladaptive thoughts, is that they don’t help you think or act appropriately

Disputing Automatic Thoughts and developing rational responses

Introduce Disputing Automatic Thoughts

First of all a therapist introduces a situation that could cause anxiety, for example you’re at the cafeteria at work and the boss comes and says can you come to my office immediately.
Get the clients to write up what are the
1.       Emotions
2.       Thoughts
3.       Behaviours
4.       Physiological responses
On the basis of getting the thoughts, then hand out the disputing questions that ask
1.       Do I know for certain that……?
2.       Am I 100% sure that……?
3.       What evidence do I have that ……? What evidence do I have that the opposite is true
4.       What is the worst that could happen ……?
5.       Do I have a crystal ball……?
6.       Is there another explanation for……?
7.       Does …have to lead to or equal….?
8.       Is there another point of view?
9.       What does …………..mean? does …………..really mean that I am a ………………..
10.   Is focussing on this helping me
Get the clients to pick an AT and dispute it using the questions. Disputing AT isn’t something that you can just do, it’s a process. AT’s are significantly embedded and require a lot of disputing and challenging to actually overcome them.  After the AT’s have been disputed, then ask the clients what the effect of disputing has been, emotionally, physiologically and physically.

Introduce Rational Responses

If you summarise all the ways in which you have disputed the automatic thought then this is a rational response. A rational response is based on logic and evidence not on emotion, cognitive distortion and pessimistic prediction
A rational response is
·         A statement of a final answer
·         A summary to the answers of the disputation of several related AT’s
·         A reminder to stay focussed on task
·         A suggestion that certain behaviours are acceptable in certain situations
·         A statement of a person’s goals in a certain situation
·         A reminder for a client to be on the lookout for certain types of AT’s
In the early stages of treatment you do not have to believe the AT but rather see it as a logical possibility, as the treatment continues, through disputing the AT then the rational response will seem more and more plausible.  It would be naïve to think that an AT that has been part of a person’s life for many years could be disputed away in one logical session, it is going to take quite a time to shift it. You can see the movement however by getting them to rate their belief in the statement.
Focusing on the rational response also has the effect of disrupting the torrent of negative automatic thoughts, potentially decentres the client and is less affected by emotion. Also taking the rational response encourages the client to take a more coping, problem solving approach as opposed to playing the victim.
Quite a few of the rational response for social phobia involve the non-equations
·         Looking nervous doesn’t equal looking foolish
·         Being rejected doesn’t equal being alone for ever
·         Not getting the job doesn’t equal never getting a job
·         Blushing doesn’t equal looking stupid
·         Feeling anxious doesn’t equal looking anxious
One other way to generate a rational response is to imagine what’s the worst that could happen, and to see how you could manage that

Homework assignment for Session 2: Cognitive Restructuring

Monitor AT’s and generate a list of rational responses using the disputing questions. Use the form in the book 10.4 and
1.       Briefly describe the situation
2.       Record the AT
3.       Record the thinking error in the AT
4.       Identify emotions related to AT
5.       Select most important AT and challenge it using list of questions
6.       Write out a rational response

Preparation for Initiation of In session exposures

1.       Tell clients that session 3 is exposure time
2.       They may feel anticipatory anxiety
3.       They may have a desire to avoid coming, or to drink or take medication beforehand, they should resist these temptations
4.       They can create rational responses for the AT’s of their anticipatory anxiety
5.       Exposure is graduated so its bit by bit
6.       Group members will be given the opportunity to discuss the situations to which they will be exposed
7.       They will learn new coping skills as they participate

11. In Session Exposures

Rationale for in session exposure

The Holy Grail for social phobia is the integration of in vivo exposure and cognitive restructuring. It is difficult to set up in vivo exposure as it requires a social setting and a complicated set of social interactions by the client, and it is this that they are afraid of.  Likewise it’s hard to repeat if you’re afraid of going outside, then you can do this experiment many times, but for a social setting then it’s harder to arrange. Social situations are also unpredictable, for instance you may get ignored or rejected, or you may spill your drink, anything can happen, which doesn’t really lend itself to experiment and practice which are two things that are needed in treatment. Likewise you really need to do a graded exposure, step by step, again this is hard in vivo. Again with exposure the rationale is to feel the anxiety and then see that it subsides, some in vivo interactions can involve the anxiety rising then the situation finishing before the anxiety drops. Again people can go to social situations but can endure them by withdrawing into themselves, in this way then they are not fully exposed to anxiety.
Therefore in session exposures are the way to go.  What is done is social situations are simulated in session, of course a group is needed to do this. However the only thing with group work, seems that clients will get habituated to the group and will know and trust them in a way that they will not with strangers

Preparation for an in session exposure

Clients generate list of feared situations
Put the list into a hierarchy
Because time is limited then you should focus on a singular goal and look for a specific type of situation with a graded task hierarchy to achieve it, so going to a party, making small talk, starting and stopping conversations.

Designing the in session exposure

You must get as much detail as possible. So if it’s a presentation arrange the furniture, is the client going to stand, is the speech going to be controversial, are the audience superiors, friendly etc. . It is important for the client to say how the other group members should behave, are they friendly, unfriendly, superior, uninterested etc. There is some difficulty here though with the set up as the person may fear people will behave in a certain way and this is the source of their anxiety, although they may not actually behave that way. The role players should attempt to recreate the actual people in the scene, but rather they should interpret the role for themselves, otherwise the gap between how they are and how the actual person is may be the explanation for any success in the role play, so may enable the client to discount the positive.

Incorporating feared outcomes

You need to be clear on feared outcomes, if I blush or sweat I couldn’t stand it, I couldn’t bear it if I was interrupted etc. You then need to expose on the basis of this. The exposures that you provide should both expose the client to their fears, which will generally be a distorted view of reality and to what is more likely to happen. Within any in session exposure with a client, then you must after the session has completed check in with them to find out how it was for them. Did they find they could overcome their fears, do they feel stronger for doing the exposure. During the exposure the SUDS ratings every minute should be recorded by a therapist

First Session Exposure

This is going to be a scary event for people watching and anticipating and the first person to go. So make sure the person selected is from the mid-range of competency in the group to not set the bar too high.  Secondly ensure that the situation is simple and the roles of the people involved simple. There will be a lot of anxiety going around and the ability to do anything complicated may be detracted.
When selecting people to role play caution must be exercised. In the early session exposure it is probably best to use the therapist. In later sessions then more of the clients should become involved and the best client would be would who can hold a conversation without withdrawing or dominating. Someone who can give reasonable feedback neither overly critical or complementary. Likewise someone who is neither going to rescue or punish the client.  It is important to think about the goals of all of the clients when asking people to role play see how this is going to impact on them being the role player for another. Of course you can get group exposure but then you will require that you have a group debrief afterwards.

Do in Session exposures make clients anxious

Some people use the artificial nature of the situation to avoid the feelings of anxiety that they would feel naturally. Once this is pointed out this can reduce this avoidance and get them to fully immerse themselves in the real situation they are symbolising
Anxiety does get produced in  in-session exposure, firstly it represents a real life anxiety provoking situation and secondly the client is being observed by therapists and by other delegates, which can in turn create anxiety of being judged. As the other group members get known to each other the initial anxiety felt might be in front of strangers, although the anxiety might maintain as it is now an anxiety about looking bad in front of peers, or loved ones.

Examples of common in session exposure

With any of these examples what is important to find out specifically what the client fears, being rejected, tripping over words, sweating and to make sure that the exposure contains this element.  So the question to ask the client is what would make this an easy exposure and what would make it harder, and pitch the exposure just outside of their comfort zone.  You also need to watch to ensure that avoidance isn’t the response to the actual feared situation, so if a client doesn’t like being watched eating then ensure in the exposure that they don’t just play with their food.
1.       Initiating conversations with a person of potentially romantic interest
a.       Fears of being rejected
2.       Public speaking
a.       Fears of being seen to be incompetent
3.       Writing in front of others
a.       Shaking=incompetent
4.       Eating in front of others
a.       Dropping something=incompetent
5.       Working\playing whilst being observed
a.       Being judged is unpleasant
6.       Assertion and interacting with an authority figure
a.       How do I say no to boss
7.       Job Interviews
a.       If I don’t get this job it will mean I’m incompetent
8.       Joining on-going conversations
9.       Giving and received compliments
a.       Go around group giving a compliment to one, then receiving to another, be on the lookout for any disqualifications e.g. using but
10.   Making mistakes in front of others.
11.   Reveal personal information
12.   Fears of being trapped in a social situation
a.       So having to disturb people to get out of a theatre
13.   Fears of being in a group
a.       Fears of ending up the centre of attention

In some situations the feared event is quite quick, so signing something and the anxiety will have failed to come down before the situation ends, so there is no exposure and fear is not faced. So in these situations then you need to either slow down the interaction or repeat it.


12. Integrating Cognitive restructuring procedures with in session exposures

Cognitive restructuring takes place after every in session exposure

Before an In session exposure

Here we have the anticipatory anxiety, so before any client does any exposure then they should have the opportunity to identify their thoughts, question their thoughts and to provide alternative rational responses.
So after a situation has been selected for exposure, then the client is asked to imagine themselves in that situation, without any editing and to report on their thoughts. Questions that are useful to elicit are
1.       What went through your mind when
2.       And what thoughts occurred to you next
3.       What was your cognitive reaction to
4.       Did you have any images about..?

In Session Exposure steps

Before
1.       Review Target situation and state goals
2.       Identify AT’s and rate belief
3.       Identify thinking errors in AT’s
4.       Question and dispute thinking errors
5.       Develop rational response
6.       Rerate AT belief
During
1.       Provide suds rating at 1 minute intervals
2.       Articulate any AT’s that occur and use rational responses generated above, if appropriate, if not save for later
After
1.       Review goals
2.       Review AT’s that happened during that there was no rational response
3.       Review AT’s that had rational responses to
4.       Review evidence for AT’s and rational response
5.       Review relation between SUDS and ATs’, were more ATs there when Suds were high
Clients may feel embarrassed to talk about their AT’s, so therapists must be ultra non-judgemental about them, but offer a sense of curiosity. To start off with clients may not report thoughts that are that easy to work with as they may be questions or two thoughts run in together.  In this instance some judicious editing may help to bring out the emotional impact of the statement.
AT’s result in anxiety as the client believes them to be true!!!!!!
With some AT’s it’s worth pressing to find out the meaning of the AT, so if an AT is he will think I’m nervous, what is so bad about this, why does it have so much emotion attached to it. Establishing AT’s also enables you to normalise feelings…who wouldn’t be anxious with all these thoughts running through your head.

Identification of thinking errors in recalled thoughts

So as a client identifies thinking errors in their thoughts the trick here is to treat it in two stages, firstly to identify the thought and secondly to state why the thinking error is an error and what the adverse effect of it is. To identify and to challenge AT’s means that you are not a passive recipient of these negative streams of thoughts but rather you challenge them and become more in control. This will reduce depressive feelings.

The process of disputation of AT’s and the production of a rational response

Once you identify the AT, then you can develop rational responses through using the list of disputing questions, or you can challenge using spot the thinking error, or you can work through in similar ways with the rest of the group.  Disputing AT’s is a process, you can’t just find the logical error once and have done with it, as these are ingrained
Rational responses can be very useful during times of anxiety
1.       Focus client on a coping message
2.       Alert the client that they have a stream of negative thoughts happening at the moment
3.       Alert the client that they need cognitive coping messages
4.       Distract the client from negative thinking and give them some perspective
An effective rational response should have the following characteristics
1.       Its content is specifically relevant to the situation in hand
2.       It is realistic
3.       It is plausible to the client
4.       It is stated in the clients words
5.       It is brief and easy to remember
As a client’s anxiety increases so their cognitive faculty will decrease. So their ability to generate rational response will decrease the more anxious they get. So simple brief questions and responses, can often help with this, as they are very direct and contain less need for energy than more verbose approaches.
Some AT’s are more strongly held than others as they form part of the person’s identity and will have many other beliefs supporting it and many other related AT’s and will form a strong support to one or more schemata. So to gain some credence to rational responses it is best to pick at AT to work on that is not central to a person’s identity or schemata. To identify one like this, then you need to really see the level of affect associated with it.
If you have a very resistant AT, say a client is convinced that he will be anxious in a situation, then you can work on it tangentially, how likely is it that he will be seen to be anxious by other people and how bad will it be if this is the case. What will then happen, is through weakening the awfulness about being anxious this in turn will reduce the fear of being anxious and will therefore reduce the anxiety!! Whilst producing a rational response in the face of a strongly held belief won’t change that belief overnight, and the client may only believe it as a logical possibility, this is a start and something useful to build on.

Common Automatic Thoughts

I won’t be able to think of anything to say

This is a common fear of people with social phobia, making small talk generally can be difficult, but making small talk with people of romantic interest or in a high power situation, can be daunting. People believe that superficial conversations are not valued in social intercourse.
To challenge this belief then you can find out when a person can make small talk, as we all can. Then compare what is it about that situation, oh I know them well, that is different. Then the belief may come out that the other person would judge you as superficial if you made small talk.
Another fear is that there will be a long silence and then the other would judge you as boring, or the silence would be intolerable and create a lot of anxiety. Some of the concerns that are around conversations is that the social phobic sees it as  a one way affair where the other can judge them, however conversation exists so people can get to know each other, maybe form judgements about the other person, maybe just enjoy talking to each other. Social phobics often overestimate the length of time a silence lasts, and it is possibly why they think it is so frightening, as at the lengths they talk about it might be problematic.  If there is a silence it is something that has happened between you, it is not purely your responsibility. Likewise with the conversation it is not purely your responsibility but a shared responsibility.

I’ll mess up

When there is a distinct outcome of a social interaction, i.e. getting the date\job\presentation delivered etc., then there is the fear that inept social performance will interfere with the end result.
To challenge this thought you need to show that you can feel nervous\anxious and still perform and even if the other sees this in you, they won’t automatically think badly of you. The rational response is generally something of the order of, you don’t have to be perfect to get what you want.

My anxiety will show and people will judge me negatively

Use a pie chart to look at how people will respond to the client’s anxiety.  So in a presentation ask how many people will notice your anxiety, if they say all, then ask if there could be any reason why people are not looking at you.  So now reduce the pie to all the people who aren’t paying attention.
Of the people who do see you, say 80% now, how many could not see you are anxious, i.e. how many times have you ever been in a mood and just not been noticed as such by someone, hmm another 10%. So of the remaining 70% how many would think it’s anxiety, as opposed to feeling unwell, or being nervous. Ok take off another 10% and of the remaining 60% how many would be sympathetic to the fact that you are anxious. Finally of those people who do think you are anxious, and do think badly of you, how many really matter to you. The result is that 2 or 3 people out of a hundred really matter to you, is that worth getting worked up about?

Automatic thoughts about the inappropriateness of behaviour

Some people think certain aspects of social interaction are wrong, e.g. blinking, or maintaining eye contact.  The challenge to this is to ask other people if they think their behaviour is wrong, or what they make of it.

Goal setting

An attempt is made to get the client to set a performance goal for exposure that is not tainted by perfection or unrealistic standards. The initial goals of clients are generally part of their anxiety or social phobia, as they must be perfect and are not which then generates the anxiety.  When they don’t reach their goals they harshly criticism themselves and the net product is social phobia. Again client goals might be woolly, such as I want to do well, this could be perfectionism under disguise, so this needs to be fleshed out. The best goal is a SMART goal. Goals must also be under the control of the behaviour of the client, such that it’s not about the woman saying yes to a date or the boss giving them a pay rise.  Goals should also be stated in terms of overt behaviour not in terms of affective states. Affects happen, you can’t stop them, they are part of the world, so the main thing is being able to work with them, to not let them stop you doing what you are doing.
Goal setting summary
1.       Specific
2.       Overt behaviour
3.       Realistic
4.       Under the control of the client
In practice goals are often stated in behavioural terms for a specified period, irrespective of emotion. So ask five questions of someone you would like to know better. Speak on a prearranged topic for 6 minutes

During an In-Session Exposure: SUDS Ratings and Rational responses

Suds are checked every minute, or if the observer notices a change in affect.  When there is a change in SUDS ask what was going on for the client, what were they thinking?  This could mean a new AT has come in, or alternatively the natural extinction of anxiety has happened.
So during the in session exposure the client has a certain goal, and if they have any AT’s they should say them out loud, and if a rational response exists for them  then they say them, if not they can be recorded for work later. The suds monitor asks them for a suds rating every minute.

After an in session exposure: the cognitive debrief


Assessment of goal attainment
1.       Ask the client did you accomplish your goals.
2.       The client needs to be able to achieve their goal irrespective of their anxiety, and should be encouraged towards this.
3.       If client fails to achieve their goal then check on the AT’s that have prevented this as they can then be targeted for exposure in the next session. Often perfectionist NATs can get in the way
Review of occurrent of AT’s and use rational responses
1.       Did the expected AT’s occur
a.       Were the rational responses used
2.       If RR’s were not used was another coping response
Review of evidence in support of AT’s versus RR’s
Were the anticipatory AT’s prior to the exposure cached out, was there evidence for or against them.  It can also be useful to ask for input from the other group participants.
Review of Occurrence of Automatic Thoughts and use of Rational Responses
After the goal review then the client should be asked if their anticipatory AT’s occurred and how they managed them, via Rational Responses, or via their own coping mechanism. If they were successful then great, if not then put these automatic thoughts onto a list for future exposure.
Review of evidence in support of Automatic thoughts versus rational responses.
Ask the clients for their anticipatory automatic thoughts, were they good at predicting what happened in the exposure session or where the rational responses more accurate. If the client things their Automatic thoughts were then you can ask what they did to make their automatic thoughts come true, did their emotions rise, did their behaviour change on the basis of having these thoughts.
With labelling automatic thoughts, then it can be useful to get other people’s opinions in the group. Of course, they may agree with the automatic thoughts, although it would be unlikely that everyone would agree with them.
In a social phobic group situation then there will be a lot of stuff going on. Clients may be compliant just to get it over with, they may not feel happy to contradict, therapist, or group think because it would draw attention to them.
Questioning Automatic thoughts in a specific one by one approach is far better than questioning general thoughts.
Some thoughts on feedback from other group members. Ask them to provide accurate feedback as much as possible and to be gentle and caring as they give their feedback. So if anxiety is seen say it, but also focus on what the effects of it were, did you still engage with what the person was saying.
Occurrence of other automatic Thoughts
Establish if other automatic thoughts came up within the exposure and if they did, then how did the client cope, was it a healthy coping strategy, if it was all is good, if not then write down the automatic thought, challenge it, create a rational response, and put it down for exposure on next week’s  exposure.
Post exposure you need to examine the pattern of suds. Draw an approximation of the suds graph and ask the client what made for the movements up and down, automatic thoughts, rational responses, behaviours in the exposure creating anxiety, or feeling that you can cope?
There are five possible patterns of suds.
1.       Spike
2.       Steady decline
3.       Habituation
4.       Asymptote
5.       Flat and level
The spike
This jagged, up and down question the client as to what makes the rises and what makes for the falls

Steady decline
Starts high and then reduces. Clients starts with high levels of anxiety, probably anticipatory anxiety, but declines when they realise they can cope. Client remains afraid of initial burst of anxiety which is where rational response are needed

Habituation
Starts at moderate, raise to High levels of anxiety, client afraid that can’t handle the levels of anxiety, but then anxiety declines. Check clients initial automatic thoughts to cause the rise, then check the automatic thoughts in the rise. So here you would have not great anticipatory anxiety, but in the situation there would be thoughts of oh no I can’t cope, I’m a disaster etc., then anxiety rises, there’s a fear that they can’t cope with this, then they realise that they can and anxiety decreases
Asymptote
Here there is a starting position of moderate anxiety, that increases to a high level and remains at that high level until the exercise ends.   This will be viewed by the client as a failure, but communicate with the client that they have got through the worst and if they repeat this it will get easier. It is also possible that the exposure task was too difficult.

Low flat line
This can mean that the client faced their anxiety and everything was fine, or that they used avoidance in the exposure, or that the exposure didn’t engage their fear, or that the exposure was too easy, you need to talk to the client to establish which this was.
Again after the exposure, the client should rerate their belief in the automatic thoughts and rational responses in light of the new evidence after the exposure.

Two common automatic thoughts that come up with social phobic clients are
1.       Everybody can see my anxiety
2.       Nobody likes me

Everybody can see my anxiety
Firstly you can approach this with a pie chart technique, i.e. who is actually watching me, of those people who can see me being anxious, of those people who cares about it, and of those who think negatively about it how many of those do I care about.
Secondly do a behaviour experiment, firstly cognitively restructure ability to be anxious and perform. Then get the client to write down what level of anxiety they think they show, in the same way as the suds rating and get the audience to rate what level of anxiety they think they can see. As the client rates herself then this her fear\belief of how her anxiety looks but when the audience rate it it’s based on the facts of her performance.  As the rest of the group give feedback then some ground rules need to be establish, honest feedback is good, if the audience see anxiety say it like it is, but also say whether or not this got in the way of the task in hand. When giving feedback, give it in a gentle and caring manner, with the aim of helping the client grow from this new piece of knowledge
Video feedback
Get the client to rate how high they think they will show their anxiety before performing the exposure.  Also get the client to say what they expect to see in the video clip and treat these as automatic thoughts to be challenged and produce rational responses. Now rate both the automatic thought and rational response.   Also ask the audience about how they would expect him to be in the video tape on the basis of how he says he will be.
Then after the exposure show the client the video. Ask them to rate their performance in terms of showing anxiety and standardly this would be a lot lower. Get them to rerate the belief they have in the automatic thoughts and rational responses, and get them to rewrite the automatic thoughts and rational responses in light of this new information.
Of course don’t use video tape if the client has skills deficiency or objective problems.


Nobody likes me
Clients have the thoughts of it people find out what I’m really like then they won’t like me. This leads them to avoiding social interactions and if they do have social interactions then they only have superficial connections.
The behavioural experiment for this is as follows:
1.       Speak for 3 minutes on something trivial
2.       Speak for 3 minutes on plans for the weekend
3.       Speak for 3 minutes on hopes, dreams and goals
The client then, once given the assignment should look at any automatic thoughts coming up and rate their SUDS, for each level. Chances are as the levels become more personal, then they would expect their anxiety levels to increase and for people to like them less., Then get them to perform their exposure and instead of writing suds down get them to use a likeability scale get the audience to do the same.

Cognitive restructuring
This can be done in a few ways
1.       Automatic thought find thinking error=rational response
2.       Automatic thought pushed through a dysfunctional thought record=rational response
3.       Automatic thought disputed with a list of challenging questions=rational response

When you’re doing a behavioural experiment, then do cognitive restructuring on the automatic thoughts you’re targeting and generate a rational response.  Put down levels of belief in each automatic thought and the rational response.  Target very specifically one of the automatic thoughts, e.g. I will get anxious and run out of the room and make this the goal for the exposure. Then do the exposure and then both rerate the automatic thoughts and rational response and rewrite the rational response possibly in light of the new evidence from the exposure.

13. Homework Procedures

·         Develop homework attitude, do it daily!!
·         First two sessions should be on automatic thoughts then homework should be done targeted to individual needs
·         Always, always, always negotiate with the client on setting homework, what do you think would be useful to work on, what would you like to improve between now and next week
·         Before doing homework then set aside a 30 minute cognitive preparation time
Cognitive preparation before homework
·         Aim to Become Your Own Cognitive Therapist BYOCT by Hall et al…
1.       Imagine\visualise the situation
2.       Record automatic thoughts
3.       Note thinking errors in automatic thoughts
4.       Challenge automatic thoughts with disputing questions and record the answers
5.       Generate rational responses
6.       Review behavioural goals and rationales
Behavioural assignment
·         See homework as practicing skills and learning not a pass or fail
·         4 parts of the assignment
1.       Cognitive preparation
2.       Enter feared situation
3.       Tolerate anxiety and stay in the situation until task complete
4.       Use cognitive coping skills as practiced in the group
After the assignment
1.       Did you meet you assigned goals
2.       Examine validity of anticipatory automatic thoughts and rerate them now there is some new evidence in town
3.       Rerate automatic thoughts and rational response in light of new evidence
4.       Record rational responses in light of any new automatic thoughts that have come up
5.       Check for any automatic thoughts after doing the homework, e.g. discounting the positive, are there any ways in which the client is preventing themselves learning from this experience
6.       Summarise what was learnt from homework such that it can be used in the future.

14. Session 3-12 Putting It All together and troubleshooting cognitive behavioural group therapy

Dos and Don’ts for clients doing exposure
·         Do throw yourself into the exposure as much as you can
·         Don’t try to avoid the anxiety by making the situation less realistic
·         Do say your rational responses to yourself as your automatic thoughts come up
·         Do repeat your rational response out loud when you give your suds rating
·         Do give suds rating quickly without worrying. Trying to be too precise can be a way of avoiding fully participating in the exercise
·         Do stay in role until your therapist says it’s time to stop
·         Don’t be discouraged if it doesn’t go as well as you would like

Timing issues

CBGT groups should last about 2.5 hours per session
Sessions
1.       30 minutes review homework
2.       100 minutes Do 3 in session exposures including homework review for the targeted clients, 10 minute preparation, 10 minute of in session exposure, 10 minute of cognitive debriefing
3.       20 minutes: develop homework for next week

Session 12

This is the penultimate one. Any exposures should address previously addressed issues, no new topics should be introduced and the aim should be to prepare the client for real life.  They should also have a review to establish what has been learnt during the previous 11 sessions, what skills have been attained, what rational responses worked, what anxiety was still left to face, what goals are they going to set themselves

Termination Issues

Encourage clients in latter stages of therapy to design their own exposure. Clients often worry they won’t be able to continue the momentum they have gained, these automatic thoughts should be looked at. Individual termination interviews should be given as opposed to group ones.

Additional Sessions

Follow up sessions should be one to one.

Trouble shooting

In session exposure

 If a client reports no anxiety then this can be because:
1.       They have fixed their anxiety  (unlikely)
2.       They are unwilling to report their anxiety
a.       Check Automatic thoughts
3.       Their feared situation may not have been exposed
a.       Check with client
4.       They were avoidant
a.       Look at the clients behaviour, did this represent reality, what were they thinking when they did it

Cognitive restructuring

·         Client has no thoughts about anxiety provoking situation. This can be because the thoughts are thought to be feelings. For instance I was very worried, what were you worried about?
·         A client might not like to call their thinking maladaptive, so design an experiment to test their predictions
·         It could also be an amygdala response and something that has been learnt through classical conditioning

Therapist problems

·         Poor time management creates problems, avoid long and detail client stories about their anxiety. Long stories may be used to avoid exposure
·         Only dispute automatic thoughts to the level that the client can remember the outcome
·         When you select automatic thoughts to dispute, then it is only worth selecting those that you can change, or make a difference to. Attack automatic thoughts from the periphery to the centre
·         Core beliefs are very solid and well-defended, intermediate beliefs\rules for living, if I do x then I get y are less defended
·         You don’t need to complete cognitive restructuring, before starting exposure, the client doesn’t fully need to believe the alternative thoughts, in session exposure is the most effective cognitive restructuring tool

Homework assignments gone awry

·         Not doing homework a major cause of the failure of CBGT
·         Clients may not naturally have the opportunity to test out their anxiety provoking situations but they must be encouraged to do so, so early homework maybe find opportunities for anxiety provoking social situations
·         If they can’t do actual anxiety provoking situations then use imagination up their feared hierarchy
·         Homework failure
o   Wasn’t set collaboratively, could be unassertive client
o   Procrastination may be an avoidance strategy
o   Homework too scary
§  Do cognitive restructuring to show homework isn’t that scary
·         Clients avoid doing cognitive preparation
·         Client doesn’t use coping statements in homework
o   Get client to visualise the situation and using coping statements
·         Client had a nasty experience, was rejected, froze etc.
o   Trouble shoot what went wrong


Summary

Social phobia. Two major sorts one fear of rejection through social interaction, the other rejection through judgement of performance, so eating, giving a presentation etc.  Both have the common feature of the fear of the all-powerful other, who will judge and reject and I can’t cope with that. The irony about this, is that they are actually creating the all-powerful other, as it is not the opinion of the other that counts, but rather then opinion they give them, that they believe they have.
The aspects of the problem are
1.       Cognitive
a.       I can’t cope
b.      They are judging me
2.       Physiology
a.       Blush
b.      Sweat
3.       Behaviour
a.       Avoidance
b.      Remember all the bad times that have happened before
4.       Emotions
a.       Fear
b.      Shame
How the work unfolds is to firstly explain how cognitions affect behaviour and emotions and the nature of automatic thoughts. From there you need to psychoeducate about anxiety and about avoidance. Then you need to introduce the list of thinking errors and show why they are thinking errors. Then you need to introduce the list of disputing questions. You also need to introduce SUDS and get the client to establish their own scale.
Once this is set up then you can start doing the work which has two aspects exposure and cognitive restructuring.
To expose, then what you need to do is to imagine the exposure and see what automatic thoughts come up about it. On the basis of these then you need to apply the list of disputing questions to it and work out what the thinking errors are. On the basis of this then you can develop a rational response to the automatic thought. You also need to get clients to identify their feared hierarchy and what it is specifically about each item on the hierarchy that they are most afraid of.
Then you need a set up an exposure with other members of the group. To do this you need a client to
1.       Identify their goal for exposure, e.g. talk to someone you fancy for 3 minutes and ask 3 questions
2.       Do a cognitive preparation.
a.       State goals
b.      Review Automatic thoughts and rational responses
c.       See if any new automatic thoughts are coming up and generate rational responses
As the exposure happens which is for about 10 minutes, then on every minute then a suds observer calls out suds and the client says what suds level they are at and reads out their rational response.  If there is any change in mood then the suds recorder will call out suds. When the exposure is finished then there can be a debrief:
1.       Was the goal achieved
2.       Chart SUDS
a.       What made for the changes in SUDS
3.       Did the rational responses help
4.       What belief is there in the automatic thoughts or the rational response
5.       Were there any new automatic thoughts, how were they coped with
That’s about it really, the length of sessions should be 2.5 hours and do 3 exposures, and you should really have about 12 sessions, which will result in 3 exposures each.


 

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