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According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, social anxiety disorder is classified through overarching features of excessive fear, anxiety and behavioral manifestations. It is the most common type of anxiety disorder, also referred to as social phobia. Social anxiety is developed and maintained by complex physiological, cognitive, and behavioral mechanisms. Today, behavioral treatment including cognitive behavioral therapy, composed mainly of short-term treatments, are among the most widely used approaches for managing psychological and behavioral problems, including but not limited to social anxiety disorder, SAD. CBT is an empirically valid form of psychotherapy that focuses on how a persons thoughts, beliefs and attitudes affect their feelings and behaviors. CBT does not exist as a distinct therapeutic technique. Through CBT, one can distinguish between facts and irrational thoughts, stop fearing the worst, and describe, accept and understand rather than judge themselves or others. There are an arrays of CBT skills used for SAD treatment such as goal setting, agenda setting, homework, relaxation, identifying and challenging maladaptive thoughts and beliefs. We will further look into cognitive behavioral therapy and the role it plays in treating clients with social anxiety disorder.
Cognitive behavioral therapy is a form of treatment that can be used with clients who have been diagnosed with social anxiety disorder. Social anxiety disorder most commonly appears during early childhood or adolescents, and most individuals with this disorder do not seek treatments. Social anxiety is actually more common than not, and that is why a lot of the characteristics experienced by people are often minimized, involving little drug or psychological interventions. While behavioral therapy is another accepted approach, CBT is still the best form of treatment for social anxiety disorder. From a cognitive perspective, anxiety consists of three components. First, autonomic hyperarousal symptoms are experienced such as heart racing, sweating, shortness of breath and trembling. The second component is negative cognitions, which can include impending thoughts of impending doom. The third component is behavioral and prototypically involved either escape or avoidance of situations associated with the anxiety. According to the NCS-R, which assessed over 9,000 noninstitutionalized individuals, throughout the U.S, found that over 12% of people have social anxiety disorder, SAD. People with this disorder report having their work, school and social life impaired by their fears. Some studies even show that people with social anxiety disorder have trouble making friends, dating, marrying and even work at jobs below their level of educational attainment. There are many fears associated with this disorder such as fear of social interactions, performance and observation fears. The DSM-V includes a performance-only subtype, focusing on individuals having to speak or perform in public. The process of this disorder begins when the individual is in the presence of their audience. People with this anxiety perceive their audience as essentially critical and as having standards that they are unlikely to meet. The image of the self is further influenced by external and internal cues. Internal cues can include anything from heart beating fast to sweating. External cues may include reactions from other people such as peoples attention or facial expressions. The fear of any evaluation, especially, negative evaluation, is sought to be the core fear in social anxiety disorder. CBT has gained substantial empirical support for their high levels of efficacy and effectiveness for treating SAD.
Different forms of treatment include social skills training, cognitive therapy, relaxation training, exposure and interpersonal psychotherapy. There are a number of measurements taken to identify those for treatment for SAD. For example, there was a study done on 58 individuals, of ages 17 and 65 among a pool of ethnicities, recruited through online postings, targeting those with elevated symptoms of social anxiety. The first tools of measurement were the online versions of the Social Phobia Inventory and the Personal Report of Confidence as a Speaker. Those who scored 19 or above on the SPIN and 16 or above on the PRCS were invited to participate with the full study (Carter, Sbrocco, 2018). Other measures of participants included The Intervention Acceptability and Helpfulness Scale, IAHS, which is an 8-item self-report questionnaire that was designed to measure views related to credibility, perceived helpfulness, likability, and predicted continued use of psychotherapeutic strategies, created by Devilly & Borkovec. Most success is made after a long period of time, sometimes up to five years. However, the combination of exposure and cognitive restructuring has been the most frequently studied form of psychosocial interventions for social anxiety disorder. Exposure to what the client fears are and cognitive restructuring are the most effective intervention for social anxiety disorder. Exposure is extremely beneficial because it allows the opportunity to test dysfunctional beliefs and generate more realistic ways of understanding the self and others. It also allows clients to experience the natural anxiety reduction that comes with staying in a feared situation for prolonged periods of time, while allowing the client to practice long-avoided behavioral skills. Exposure based CBT is the treatment of choice for anxiety disorders (Craske, 2015). Exposure therapy usually starts with a situation thats only mildly threatening and works up from there. This step-by-step approach is called systemic desensitization. This allows for gradual challenges of fears, building confidence, and mastering skills for controlling panic. The patient is taught relaxation skills in order to control fear and a hierarchy of fears are created. Cognitive restructuring allows the client to learn to treat their anxiety-provoking thoughts as hypothesis. The therapist will help the client restate a question as a statement of what he or she feared. For example, instead of a client asking themselves, what will other people think if me , the client can think, other people will think I am unprepared for this presentation . Cognitive restructuring allows a client to identify errors such as fortune-telling, mind reading and catastrophizing among others. Behavior therapy emphasizes the importance of learning, both in the development of behaviors and the strategies for changing them (Shikatani, B.K., Anthony, 2019). Both cognitive and behavior therapy are empirical, present centered, and problem oriented, requiring explicit identification of problems and that situations in which they occur, as well as of the resulting consequences. For example, simple exposure to anxiety filled situations while verbalizing negative automatic thoughts may lead to improvement on cognitive measures. The more clients view the situation as less threatening the more willing they would confront their fears. When their fears are confronted, social tasks and performance may increase. The sooner a client is able to assess the situation as non-danger the situation becomes more realistic, allowing the psychological symptoms to diminish. With these forms of treatment, there should be a reduction in symptoms pertaining to this disorder, improved functionality, as well as an overall positive sense of well-being and life satisfaction.
The main role the therapist plays is to help the patient clarify goals, and a strong way to achieve this is through a collaborative relationship. The ideal therapist has a strong background in the theoretical underpinnings of CBT for anxiety disorders, experience conducting exposures, good basic therapy skills, and experience with social anxiety in particular. The cognitive therapist does not tell the client that the beliefs are irrational or wrong or that the beliefs of the therapists should be adopted. Instead, the therapist asks questions to elicit the meaning, function, usefulness and consequences of the patients beliefs; CBT is not the substitution of positive beliefs for negative ones. It is based in reality, not in wishful thinking. Cognitive change can promote behavioral change by allowing the patient to take risks. The therapist maintains a right therapeutic alliance at all times. The therapist functions as a guide who helps the patient understand how beliefs and attitudes interact with affect and behavior. The therapist is also a catalyst who helps devise corrective experiences that lead to cognitive change and skills acquisition. The role of the therapist is to actively pursue the patients point of view by using warmth, accurate empathy and genuineness. The therapist specifies problems, focuses on important areas and teaches specific cognitive and behavior techniques. To continue to maintain collaboration, the therapist elicits feedback from the patient, usually at the end of each session. Feedback focuses on what the patient found helpful or not, whether the patient has concerns about the therapists or overall therapy, and whether the patient has questions. Another form of collaboration is when the patient is provided with a rationale for each procedure used. This allows for a better understating of the therapy process, increases patients participation and reinforces a learning paradigm in which patients gradually assume more responsibly for therapeutic change (Wedding, Corsini, 2019).
The therapeutic relationship is collaborative. In cases of sever social anxiety, clients may initially need the therapist to take a directive role. As part of the collaboration, the client provides the thought, images and beliefs that occur in various situations, as well as the emotions and behaviors that accompany the thoughts. The client also shares responsibility by helping to set the agenda for each session as well as doing homework between sessions. Homework helps therapy proceed more quickly and gives the patient an opportunity to practice newly learned skills and perspectives. Some homework may include, talking to strangers, speaking up in groups or giving presentations, being assertive, revealing personal information about oneself, and feeling less embarrassed about visible anxiety symptoms. An alliance refers to the affective quality of the client-therapist relationship and the level of client-therapist agreement with the therapeutic activities. Both alliance and client involvement are considered critical to the success of CBT for social anxiety (Mcleod, et al., 2013). Client involvement is defined as the clients level of participation in therapeutic activities and has been linked to positive outcomes in CBT for SAD.
Cognitive behavioral therapy emphasizes a relationship between peoples belief systems, their emotions and behavior (Wedding, Corsini, 2019). However, studies have shown, that along with CBT, mindfulness and acceptance and commitment therapies have similar findings when dealing with anxiety disorder (Wedding, Corsini, 2019). Some of the goals throughout treatment are to help clients by providing corrective learning experience that lead to changes in behavior, broadly defined. According to an individual CBT for social anxiety disorder, a treatment can comprise of 1-hour sessions within a period of 16-20 weeks. A workbook is included for homework purposes, and chapters have to be read preferably before each session. The workbook is brought to each session, with both the therapist and client having the ability to write down key concepts. Writing things down during sessions help clients better to track and process the information being covered and is a required component of the treatment. Therapists are expected to help clients to experience and deepen affect as appropriate to the situation. The client and clinician need to reach a joint decision that social anxiety will be the focus of treatment. The patient should always be reminded of the original treatment contract and goals, and encouraged to avoid avoidance. Throughout treatment, the client practically becomes his/her own therapist through the learned and implemented coping skills that results in a reduction of anxiety and an improved daily functioning.
CBT models argue that dysfunctional cognitive schemes sustain maladaptive behaviors. The aim of the therapist is to challenge the patients core beliefs, which are believed to maintain dysfunction or psychopathology. The therapeutic relationship is regarded as third wave . Third wave cognitive behavioral therapies are a group of merging approaches to psychotherapy that represent both an extension of and deviation from traditional CBT approaches. Unlike traditional CBT, the third wave behavioral therapies focus on changing the function of psychological events that people experience, rather than on changing or modifying the events themselves. Critics of these approaches maintain that the collaboration is actually an attempt to get the patients to conform to and comply with the therapists advice and guidance. Is it important that the therapist is not biased, or mistakenly changes the clients views to reflect society, or their own view. Therapeutic relationship may be negatively affected if the collaboration is not kept, and will continue to evolve as a by-product of the process. Some view the therapeutic relationship as secondary in relations to the techniques being applied throughout treatment. The relationship needs to be a partnership in which both the therapist and clients are working together to reach the clients goal.
Social anxiety disorder is conceptualized as excessive function or malfunction of normal survival mechanisms. Psychological responses prepare the body for fight or flight. The anxious persons perception of danger is either based on false assumptions or are exaggerated. Anxious individuals have difficulty recognizing cues of safety and other evidence that would reduce the threat of danger. Self-monitoring is a CBT technique that refers to the systemic observation and recording of ones behaviors or experiences over a period of time. This technique could be useful as a therapeutic intervention because it helps the patient to evaluate his/her thoughts, emotions, and behaviors, recognize the feared situations and find appropriate solutions. Assertiveness training can be an effective part of treatment for those who wish to improve their interpersonal skills and sense-respect and it is based on the idea that assertiveness is not inborn, but a learned behavior. In other words, anyone can learn to be more assertive. Role-playing can be done with the therapist in order to acquire assertiveness training skills. Behavioral techniques are designed to challenge specific maladaptive beliefs, promote new learning, as well as to expand patients response repertories, relax them or make them active, prepare them for avoided situations or expose them to feared stimuli. These techniques foster change and is crucial to know the patients perceptions, thoughts and conclusions after each behavioral experiment (Wedding, Corsini, 2019). Relaxation training is a behavioral technique where the client learns breathing retraining, guided mental imagery and progressive relaxation. The goal of CBT is to correct faulty information and help patients modify assumptions that maintain maladaptive behaviors and emotions. CBT and behavioral methods are used to challenge dysfunctional beliefs and promote more realistic adaptive thinking. CBT initially address symptoms relief, but its ultimate goals are to remove systemic biases in thinking and modify the core beliefs that predispose the person to future distress. In cases of anxiety, cognitive content revolved around themes of danger or fear. The Liebowitz Social Anxiety Scale (LSAS) was used in a research study to assess social anxiety symptoms severity. The LSAS has been shown to be a reliable measure for the assessment of individuals experiencing social anxiety (Barlow, 2014). Researchers have investigated the efficacy of a broad range of treatments for social anxiety disorder, including social skills training, cognitive therapy, relaxation training, exposure, interpersonal psychotherapy, dynamically oriented supportive psychotherapy and various pharmacotherapies. In a study conducted by Heimberg, Dodge, and colleagues, treatment was compared to an attention control treatment that comprised education about social anxiety disorder and nondirective supportive group therapy. Findings reported that less anxiety was experienced during an individualized behavioral test (Barlow, 2014). Other measure of social anxiety is the Social Phobia Scale, which assesses fear of being observed by others. Multiple studies suggest that the SIAS and SPS are reliable and valid measures, sensitive to the effects of CBT.
Therapists without a string background in CBT or exposure therapy may be at risk for changing the focus of treatment too readily. The issue of the CBT therapist adjusting the client to the norms of societally sanctioned roles remains a strong challenge to this approach. A major ethical issue is that CBT therapist run the risk of imposing a socially conformist ideology on the client (Wedding, Corsini, 2019). However, researchers of psychological treatments should consider including credibility and acceptability as variables. Behavioral tests demonstrate that the anxiety measurements reports are largely inaccurate and are essentially example of distorted beliefs. Another issue arising from this theoretical orientation is that there are relatively few psychotherapists who have the training and experience to qualify them as experts in CBT. It takes a skilled clinician to be able to motivate patients to change behaviors that occur in the context of strong and long-standing reinforces. CBT therapists often run the risk of being unnecessarily verbose and dominating sessions. This can result in receiving less input from the patient resulting in a case formulation that is not collaboratively derived. Other common errors in this approach are when the therapist inadequately defines goals that are disconnected from the patients presenting problem and this happens when a detailed functional analysis of the problem is not conducted. Another clinical error is getting stuck in the cycle of exploring and challenging beliefs when a behavioral approach will do (Kim, S.D, Olatunji 2016).
Experience in applying new behaviors can validate the new perspective. Emotions can be moderated by enlarging perspectives to include alternative interpretations of events. Emotions play in cognitive changes because learning is enhanced when emotions are triggered. Thus, the cognitive, behavioral and emotional channels interact in the therapeutic process. However, CBT emphasizes the primacy of cognition in promoting and maintaining therapeutic change. Aside from these applications, issues arise with these theoretical approaches. Sometimes peoples personal beliefs are at odds with the cultural values around them. Other times, a persons beliefs may be changing with cultural changes and discrepancies may cause distress (Wedding, Corsini 2019). There was a study on participants of different demographic with a number of perceived barriers to treatment were examined for social anxiety disorder. Barriers to this treatment included shame, stigma followed by logistical and financial barriers, with more barriers experienced by ethnic minorities. Increased education and culturally sensitive outreach initiatives are needed to reduce barriers to mental health treatment. Fear of what others might say was among the top barriers to seeking treatment for social anxiety (Barlow, 2014).
Several recent studies have found that common measures of anxiety developed from a cognitive framework and validated among non-Hispanics Caucasians are not culturally equivalent psychometrically among African Americans. According to a CBT model of anxiety, based on African Americans, ethnic identity is thought to influence those who seek treatment. For example, if one strongly identifies with African American cultures, one might have less trust in Western treatment approaches and consequently be more likely to seek alternative sources or no treatment altogether (Carter, Sbrocco, 2018). Through a recent study developed specially for African Americans, a basic CBT model was used as treatment, however implications of cultural equivalence needed to be assessed. In other words, ethnicity matters. The overall concluded many findings, such as that anxiety disorders have more chronic course among African Americans even after a 2-year treatment. Evidence has shown that African Americans were more likely to report greater pathology than their non-Hispanics counterparts, and that the use of the SIAS could lead to biased conclusions in the interethnic comparison. For example, these measurements might represent a performance concern rather than in interaction concern. However, reports showed significant improvement in symptoms that was maintained at a 4-month follow up period. With a diverse population, CBT may be an issue due to the race-related stress of being African American. This stressor directly affects their expression of anxious pathology and plays an important role in the development and expression of anxiety symptoms. For example, to African Americans, what may appear to be social anxiety may be based on the belief that others are paying attention because of their ethnicity, being African American, and not because of inadequacy on their part (Carter, Sbrocco, 2018). Authors postulated that what one learns to fear, how one interprets symptoms, and where he or she seeks treatment are inextricable linked to the concept of ethnicity. In a World Mental Health Japan Survey, findings estimated lower rates of SAD prevalence in Asia compared with Western countries. But issues arose because this form of therapy and interviewing was not suitable for Asian people. The face-to-face interview may have inhibited participants from answering the questions truthfully. Similarly. Japanese people also suffer from a culturally specific type of social anxiety, which is characterized as a fear of offending others (Shirotsuki, Nomura 2014). A challenge with CBT is finding ways to encourage clients to use methods that may not fit with their cultural assumptions and beliefs or to adapt behavioral methods so they are more consistent with the clients values or expectations. Overall, culture can influence a clients behaviors and response to treatment in many ways. Culture may also affect most psychotherapies, clients reactions to the therapist, and cultural difference may create language barriers that make psychotherapy difficult. For most psychotherapies, there is relatively little research on treating individuals from ethnic minority groups, including cognitive behavioral therapy (Wedding, Corsini, 2019).
Overall, cognitive behavioral therapy is skills-focused treatment aimed at altering maladaptive emotional responses by changing the patients thoughts, behaviors, or both. Cognitive therapy focuses on changing cognitions, which is proposed to change emotions and behaviors. Exposure therapy, cognitive restructuring, applied relations, and many other techniques have yielded great results in the treatment for many anxiety disorders. Treatment is dependent upon the relations between the client and the therapist. It is vital that the therapist focuses on developing a level of trust with the client, providing empathy and support, to encourage the client to feel safe in expressing his/her symptoms. It is important that the therapist discusses and revisits treatment plans/goals, as well as assign psychoeducational material on the specified disorder. The client must be actively involved in his or her own recovery, having a sense of control throughout the treatment process. CBT is short term, but most effective with follow ups. CBT works by providing a hands-on practical approach to problem-solving.
All in all, cognitive behavioral therapy helps you learn to control thinking, maintain that control and self-confidence and learn new coping skills that are helpful throughout ones entire life.
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