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.
