Social anxiety is a normal reaction that most people experience at times in their relations with others. However, social anxiety disorder (SAD) goes beyond this to the point where it causes persistent and significant distress and interferes significantly with the person’s life. This will be reflected in the case study to follow in which Paul a 26yr old man was referred to the cognitive behaviour therapy (CBT) team with experiences of significant distress in social situations. The core of social phobia appears to be a robust need to deliver a particular positive impression of one-self to others and there is noticeable uncertainty about one’s aptitude to do so (Clark and Wells 1995). Social anxiety is defined in the diagnostic and statistical manual (DSM) -5 (APA 2013) as where the fear, anxiety, or avoidance is persistent, and typically lasts 6 or more months.” Further, to this Moscovitch (2009) suggests that social anxiety comprises a view of the self as deficient in social skill, social anxiety, social value, and character. At a pathological level, SAD affects functioning in all features of everyday life, including professional functioning, social activities and relationships.
Social anxiety disorder is among the most common psychological disorders, affecting approximately13% of individuals at some point in their lives (Kessler et al 2012). It is likely to occur in conjunction with other anxiety disorders within 70 % of the adult population followed by any affective disorder (up to 65%), and substance-use disorder (about 20%) (Fehm et al 2008). For Pau,l the use of alcohol was identified as a coping mechanism for managing his social anxiety. In order to address Paul’s experiences of social anxiety, cognitive behaviour therapy (CBT) is regarded as the most effective evidence based treatment (Hofmann and Smits 2008).
During the initial session Paul was informed regarding the issue of confidentiality, which I was ethically and legally obliged to advise him about under the Code of ethics and regulatory requirements as per HSE guidelines. I outlined to Paul that there were a number of situations in which I would be legally required to break confidentiality – any issues regarding abuse of children or vulnerable adults, by a court of law (although this was unlikely to occur it was important to be upfront and transparent from the beginning as this would assist in formulation of trust within the relationship), and finally if based on my clinical judgement and assessment that Paul was a risk to himself or to anybody else that I had both a professional and legal obligation to break confidentiality. I reassured Paul that people who seek support may have thoughts of possibly wanting to harm themselves but that we would be able to work through these and if necessary access specific help to support him.
Therefore all necessary professional ethical guidelines/forms required were approved and signed before therapy began. It was also important to assure Paul that as a trainee therapist that I was bound by a code of conduct and that I would also be undertaking clinical supervision to provide me with support for dealing with any difficulties experience by either him as the client or by me as the therapist during therapy sessions. The supervision was provided in one to one fortnightly sessions by an accredited supervisor whom was also a practicing CBT therapist.
Therapy began with a detailed assessment and formulation of the problem, which was developed collaboratively between Paul and the therapist. My aim was to understand the development and maintenance of the disorder and the manner in which Paul’s current beliefs, emotions and behaviour interacted. It was also important initially to assess the problems that Paul was seeking to change (Mcleod 2009 ), and to gather as much information as possible from Paul regarding his expectations of therapy and what was expected from him during therapy with regards to the collaborative process of CBT and compliance (Westbrook et al 2007). Treatment goals included being able to engage in conversations within group settings without excessive anxiety and to feel more confident in disagreeing with other people.
Following on from eliciting background information from Paul the next part of the process was to develop a formulation or life map with Paul, which would provide our compass to treatment. The formulation would assist me as the therapist and Paul to understand how all his disorders and problems were related, describing the unique features of these disorders and problems, and to design and carry out an effective treatment plan.
During the process of completing the formulation Paul’s life line was divided into three areas – age 0-5, age 5-12 and finally age 12 to present. There were specific questions that were asked during each of these time frames which had been resourced as part of the learning process which the therapist experienced during clinical supervision. These provided an insight into Paul’s experiences in life. Paul was unable to identify any particular issues or negative experiences in his earlier life 0-5 years. He was the middle child of five siblings and described a good relationship with his siblings. He began primary school at age five and has memories of the first couple of years as been ‘fun’ and he remembers having a number of friends. However, Paul was able to identify that towards the end of primary school he began to experience “pains in my stomach” for which he would stay at home from school for. The onset of social phobia usually takes place during adolescence, although a minority of causes involve a late onset after a significant life event (Veale 2003).
He was investigated from a medical perspective for these pains but no medical explanation was identified. Paul was able to identify that around this time he began to become increasingly self- conscious amongst his peers and this increased in intensity when he transitioned into secondary school. Through-out secondary school Paul continued to experience these ‘pains’ and was absent from school for periods of time. Paul was able to identify that his level of anxiety also increased and he began to withdraw from his peers and from social events. This continued into third level education whereby he eventually stopped attending college and withdrew even further from social situations and from friends. This has been recognised by Van Ameringen et al (2003) in that educational achievement can be undermined, in individual who experience social anxiety with an increased risk of leaving school early and obtaining poorer qualifications.
There are a number of assessment measures which can be utilised by the therapist to assess the level of social anxiety symptoms. These assessment measures include the Brief Social Phobia Scale (Davidson et al 1991) and the Social Anxiety Scale (Liebowitz 1987), which are both observer-rated. Subjective rating scales include the Social Phobia and Anxiety Scale (SPAS) (Turner and Beidel, 1989), the Social Phobia Inventory (SPI) (Connor et al 2000) and the Fear Questionnaire (Marks and Mathews 1979). For Paul the SPAS and the SPI were utilised and the scores correlated with marked impairment.
Clark and Wells’s (1995) social anxiety disorder model was utilised to understand the maintenance of the social anxiety cycle. Paul was asked to describe in detail a specific and recent social situation that was sufficiently anxiety-provoking. This involved his attempt to attend a group CBT therapy within a resource centre. However, his level of anxiety was so great that he attended the first session but did not attend any further sessions. As the therapist I then attempted to identify the negative automatic thoughts by asking questions such as: ‘What went through your mind as you noticed yourself becoming anxious about the group’, ‘What was the worst you thought could happen?’ and ‘What did you suppose that others would notice or think? ’
Paul had automatic thoughts such as ‘I will go blank if the therapists notice my anxiety, or if they question my opinions’. His belief ‘I always need to look competent and smart in front of others’ activated these automatic thoughts. Automatic thoughts generated somatic symptoms in Paul which he described as ‘butterflies in his stomach, heart palpitations and sweating. This presented an opportunity to undertake psychoeducation with Paul in relation to the physiology of anxiety. He also experienced cognitive symptoms in that his mind went empty and it was enormously stressful for him to endure the situation.
This analysis provided clear information about Paul’s thoughts, feelings, physiology and behaviour in this specific situation. As Paul described what had happened during the group, I noted the details down, scripting each element in the positions they appear within Clark and Wells’s (1995) model of social anxiety. I shared and clarified the conceptualisation of the problem as the sessions progressed, with Paul adding in the different connections when they had been collaboratively agreed. The connections included – the triggering social situation (being asked an opinion within a group of individual he was not familiar with) which activated Pauls assumption that ‘If I put myself forward others will see I’m stupid and reject me’. This hypothesis led to Pauls perception of social danger that others would perceive him appearing anxious and not managing (sweating, shaky voice, etc.) and would reject him subsequently founded on this. This sense of social danger led him to assume numerous safety behaviours.
All three elements, his perceived sense of social danger, the safety behaviours and the anxiety symptoms, fed straight into an overwhelming sense of self-consciousness, which incorporated descriptions of himself from an observer perspective within the group. This image of himself preserved his sense of social danger, further stimulating his safety behaviours and increased his anxiety symptoms, generating an uninterrupted feedback cycle thereby sustaining his social anxiety. The formulation and assessment were completed over a number of sessions with a summary of the problems outlined to Paul which would assist in demonstrating my understanding of his experiences and allow for clarification.
Whilst undertaking the assessment I was fully cognisant of the Pauls sociocultural context which needed to be taken into account when making a clinical judgement regarding Paul description of the level of fear he experienced as this is in keeping with the criteria of the
DSM-IV (APA 2013). Social anxiety disorder is directly linked to culturally dependent social standards and role expectations and therapists sometimes need to challenge social norms in order to address patients’ maladaptive beliefs (Hofmann et al 2010). As a therapist I need to be aware of the factors that contribute to the differences in social anxiety and social anxiety disorder between different cultures, including their uniqueness, the individuals’ perception of social norms, gender roles, and gender role identification. Therefore it was imperative to take Pauls sociocultural background into consideration when evaluating his social behaviors and attitudes (Hofmann et al 2010).
Cultural context in which individuals grow up exerts a large influence on the aetiology and maintenance of social anxiety (Lewis-Fernandez et al 2010), and thus on their physiological reactivity in different social contexts. Therefore when working with Paul it was fundamental to have a correct sense of the context of his life and the social norms that he grew up with as this would assist me as a therapist in formulating an overview of his experiences.
As a novice CBT therapist I was also acutely aware of my level of therapeutic competence. Competence as a clinician refers to my skill in conveying a specific therapeutic intervention and to mediate towards psychological change. Therefore it was important to reassure Paul from the commencement of therapy that I would be guide in my practice by a clinical supervisor who was also a CBT therapist.
When working with Paul there were a number of models of practice which could be utilised within CBT. It was important to identify which model would allow for the most effective therapeutic outcome for Paul. Therefore, Clark & Wells (1995) and Clark (2001) cognitive model for the management of social phobia was employed. With this model I was able to identify that there are three aspects of social phobia that were maintaining Paul’s social anxiety. These were his level of self-consciousness, his patterns of thinking and his safety behaviours. Therefore these were the factors to focus on during treatment. Pauls patterns of thinking were hidden in his beliefs and assumptions that he was ‘useless’ and that he needed ‘to be perfect in order for people to like me’, and in the thoughts that make his social situation seem to be dangerous ‘this is horrible’, ‘everybody is staring at me’. The safety behaviours that Paul used include all means of protecting himself when this happens – from keeping averting his eyes during conversations to saying very little so that he would not say anything wrong.
The four-system model (Greenberg and Padesky 1995) is another CBT model that assists with gathering assessment information in a way that helps make sense of things. The four systems comprise of thoughts, physiology, moods and behaviour. As these systems are intertwined, change in one area impacts each of the other areas. Although the four-systems model is an effective tool for collecting information and demonstrating the components of CBT, it does not describe how a problem is sustained and is not therefore appropriate as a tool for formulating problems, as the maintenance element of any formulation is fundamental to understanding how treatment will proceed (Skinner et al 2014).
A further model of understanding five aspects of a client’s life and building a cognitive-behavioural formulation is the ‘Hot cross bun’ (Greenberger and Padesky 1995). The five aspects represented include; ‘cognition’, ‘physiology’, ‘mood’, ‘behaviour’, and ‘environment’. Cognition, physiology, moods and behaviour interact and equally they occur within and are influenced by the environment. Using the hot cross bun as can be helpful in defining where the client’s problems primarily are and where to target intervention.
Throughout the process of delivering CBT the fostering and maintenance of the therapeutic relationship was crucial. For therapy to be successful there must the presence of a relationship between the client and therapist (Gelso 2011). If there is no relationship then little to nothing can be accomplished in therapy (Mozdzierz et al 2009). Social anxiety is fundamentally an interpersonal disorder which tends to affect relationships negatively (Alden 2005), and therefore as a therapist it was important to pay particular attention to establishing the therapeutic rapport from the outset when assessing for Pauls social anxiety disorder. Socially anxious individuals commonly experience insecurity about their capacity to engage in therapy and may fear being exposed by the therapist as being inadequate in some way (Skinner et al 2014). As Paul’s therapist I was particularly cognisant of building trust from the outset by showing appropriate levels of empathy and warmth in both my verbal and non-verbal manner.
The early establishment of a therapeutic alliance is significant in that the alliance is a predominantly useful predictor of outcome when recognized and measured early in treatment (Castonguay et al 2006), and premature termination of treatment has been empirically connected with establishment of inadequate early alliance (Constantino et al 2002). Further to this, I was conscious of assuming a genuine and honest therapeutic style which encompassed acknowledging any problems that might arise during the assessment because of the social anxiety (James et al 2001). Paul was encouraged to take an active role in the therapy and work towards becoming his own therapist.
During the initial assessment Paul spoke quietly and with eyes averted at times, which made him difficult to hear and to engage. I was able to recognise that speaking quietly was likely to be a behaviour that Paul was adopting to try to keep him-self safe socially. Safety behaviours are utilised by socially anxious people in an effort to decrease their anxiety in situations they find problematic. For Paul, the safety behaviours of speaking quietly (so as not to draw attention to himself) and averting his gaze meant that as the therapist I could not hear Paul properly, and during the initial session when I was trying to establish a therapeutic relationship it was difficult to use my non-verbal expressions to convey empathy and encouragement. Therefore these behaviours prolonged the assessment and drew more attention to Paul, while also preventing effective, meaningful communication.
As Paul’s therapist I was aware that safety behaviours would be an important feature of social anxiety he was experiencing, and therefore I was alert to recognising these behaviours from the commencement of therapy. It was important that in order to foster a strong therapeutic alliance with Paul based on trust and honesty that I would not continue to allow Paul to be unheard during the sessions, consequently I acknowledge to Paul the difficulty I was experiencing, asking if Paul would mind speaking louder. Paul experienced some slight discomfort at this request but responded more loudly and reflected that at times people would have difficulty hearing him and would often have to repeatedly ask him to repeat himself which would increase his level of anxiety. I responded to Paul by saying that it was much clearer when he spoke more loudly, and that I was really interested in hearing what he had to say, so that I could understand his experiences in order that we could collaboratively make sense of these experiences.
Forming a positive relationship with Paul was central to an effective therapeutic alliance, yet as in all effective relationships this is built upon mutual trust and confidence in the other person. As a therapist I needed to demonstrate Rogers’s (1980) core components of empathy, genuineness and positive regard, so that Paul would feel able to engage, trust me as the therapist, and have confidence in the relationship. An expression of empathy would validate Pauls responses through demonstrating an interest and identification with his perspective and experience. In responding in a genuine manner towards Paul there would be a sense of credibility, honesty and professional identity within the relationship, which would also foster a sense of constancy and authenticity. Finally the unconditional positive regard component which pertains to treating Paul with respect, and without the biasing influences or expectations of preconceptions or stigma would further assist towards solidifying our relationship.
Dryden and Reeves (2013) contend that the collaborative feature of CBT contributes to reducing misinterpretations which may influence the therapeutic relationship and therefore within CBT the therapeutic relationship itself does not develop as the prominent characteristic of the therapy. Therefore as the therapist my role was to support Paul in outlining his goals for therapy and the resources for realizing these goals and this was elicited by utilising an approach which conveyed an expertise about cognitions, behaviors, emphasized a scientific approach toward testing the validity or usefulness of particular techniques in relation to cognitions and behavior (Friedman and Thase 2007).
Socialising Paul during the early phase of the therapeutic process to the CBT approach was another opportunity to foster the therapeutic alliance. This involved explaining to Paul the principles of CBT, the evidence-based for CBT, how and why assessments are important, the necessity of completing homework outside of sessions and the potential interventions which would be available for Paul. This socialisation to CBT also allowed for Paul to give his informed consent for the therapy to continue which Daniels and Wearden (2011) suggest leads to higher success rates where agreed treatment goals between the therapist and client are established. Roos and Wearden (2009) reflect that socialisation enhances the possible benefits of therapy and the therapeutic alliance developed during the socialisation process can have a noticeable impact on treatment result.
However, it would be difficult for Paul to engage in effective therapy unless he felt safe and confident to talk about his personal problems. Within the arena of social anxiety many of the issues which Paul brought to therapy have an interpersonal component, and there is the potential for similar interpersonal problems to be activated in a therapy session. It was important to be aware that both Paul and I would both bring beliefs about ourselves and others to the therapy relationship and this could have an impact on the way therapy was done both in a positive and negative manner . It was therefore important that as a therapist that I recognise the beliefs about self and interpersonal relationships which could lead to me experiencing unexpected emotional and behavioural responses in my therapy situation with Paul, which could be detrimental to a productive and helpful therapeutic relationship.
Therefore, as a therapist I was cognisant of the need to pay attention to any negative or positive reactions towards Paul and be vigilant for signs of strong negative emotions, in the therapeutic relationship as these had the potential to lead to ruptures within the relationship (Vyskocilova et al 2015). Ruptures range in intensity from minor tensions which either myself or Paul may be only vaguely aware of, to major breakdowns in collaboration or understanding (Safran et al 2011). When as a therapist I can work through negative process and repair ruptures in the alliance, the outcome for the clients I work with may have better outcomes. Therefore as Goldfried (2013) maintains it is crucial for therapists to learn to manage their personal reactions toward patients, to preserve a positive therapeutic alliance. Further, the assistance of and discussion with supervisors and colleagues is useful in regard to countertransference even in experienced therapists (Goldfried 2013).
Awareness of my own belief systems which relate specifically to the way as a therapist that I perceive myself within the therapeutic context is also fundamental to the therapeutic alliance. Some of these belief systems that I became aware of involved demanding high standards including a high expectation of Pauls improvement and his compliant attendance at the therapy sessions with a strong expectation within myself towards the completion of homework assigned during the sessions. This was addressed by discussing my expectations within my clinical supervision and also by completion of the Therapist’s Schema Questionnaire (TSQ) (Leahy 2001). My responses to the TSQ highlighted some areas that needed to be addressed within clinical supervision and challenged and which would be significant in my professional development.
Further also as a therapist I was aware of not engaging in recommendations, advice, and questioning that Paul would ask, as that would involve imposing my own goals upon Paul (Higginson et al. 2011). Therefore during my supervision I addressed indications of any conflict between my own goals and those of Paul, including making sense of any indirect changes in affect or behaviour. Hence, by purposefully monitoring goals and their incongruity in the present moment of therapy, Paul would experience his therapist as being non-judgemental, warm, and empathic (Higginson et al 2011).
It was important also during the course of therapy tobe mindful that individuals with mental health difficulties frequently have an extensive variety of requirements that may be social and psychological and my require input from a wider range of professionals. A significant forte of multidisciplinary teams is that the collective proficiency of a range of mental health professionals is employed to deliver unified, comprehensive care to the individual (Mental Health Commission 2006).
Fernando and Keating (2009) suggest that the cognitive behaviour therapist role within the multidisciplinary team will differ significantly. Working as part of a multidisciplinary team provides me with opportunities to augment both my own clinical work and that of my colleagues within the team. However, as part of my role within the team I need to be open to the viewpoints of other colleagues which will allow me the opportunity to acquire knowledge about the other therapeutic approaches within the team and how these methods can be beneficial to the client I am working with. My own experiences working as a CBT therapist and the skills base I am accumulating including use of formulation, collaborative working, use of Socratic questions, can be shared within the multidisciplinary team.
However, as a member of the MDT I am also challenged with the additional responsibilities, accountabilities and dilemmas that may arise when working with other professionals within the team, rather than working as a more independent practitioner or private practitioner. Therefore, the culture within the team can have a significant impact on the working of that team and there may be guidelines and regulations governing the operational system of that team which may be in direct conflict with principles and practices which also govern my CBT practice. It is essential from the outset of joining the team that I am in a position to establish my individual role as a CBT therapist within the multidisciplinary team. Within my current area of practice there are already a number of CBT therapists in place and a transparent pathway has been established in terms of expectations, roles and boundaries. Onyett (2007) emphasises that in order that a team will operate efficiently that transparent and distinct roles are established.
Currently within the MDT the cognitive behaviour therapists are integrated within the team, and there are clear boundaries in relation to their individual specialist skills. These boundaries are largely recognised and there is generally an understanding of the role of the CBT therapist. However, there are times when the referrals that are received by the CBT team that are inappropriate and as Veale (2008) suggests the MDT team can provide opportunities to address the appropriateness of clients for CBT. In order to be able to offer rationale within the MDT for these decisions I have a responsibility to keep abreast of current evidence based practices. As conflict can arise within the MDT meeting regarding differences of opinions about approaches with clients, this requires me to have the evidence base to rationalise my decision in a clear and knowledgeable manner.
The focus of my CBT interventions with Paul, were to target his thoughts, feelings and physical experiences with the purpose to create positive changes in Pauls emotional state. It was necessary for Paul to understand the role emotions played in maintaining his difficulties, therefore, I undertook some work with Paul on his emotions. During the initial part of his assessment Paul admitted to using alcohol to manage his emotions but he had difficulty identifying and naming these emotions. He would often experience a low mood for a few days following a ‘drinking session’. Therefore, if Paul had difficulty in identifying emotional states, this would have an impact on his therapy, and make it less effective, as he would not be able to see the link between specific thoughts and the emotional responses to them.
Given that the CBT interventions that I would be utilising with Paul would be in relation to his social anxiety, and would involve some exposure work, I was aware that the interventions would have the potential to lead to an increase in either the frequency or intensity of the experience of certain emotions for Paul in the short term. Consequently, it was important that Paul would have the skills to endure uncomfortable emotions. As Paul had already identified that he used alcohol to cope with feelings of anxiety and stress, the work we completed on coping with his emotions was an important aspects of our collaborative work.
Another important aspect of managing the emotional content associated with therapeutic sessions was in relation to the emotions within myself as the therapist which can arise during the sessions. Therefore, as a novice practitioner attendance at clinical supervision and the opportunity to process my own emotional response was very important. Part of this journey involved completing a reflective journal following each session in which I could document my own emotions.
Although the impact of transference and countertransference are normally associated with psychoanalytic psychotherapy, both clients and therapists within the CBT process can experience strong emotional reactions towards each other in what are termed transference and countertransference within therapy (Prasko et al 2012). However, Prasko et al (2012) further adds that it is the manner in which these emotions are managed and utilized within therapy which matters. Therefore recognizing transference in the therapist-patient relationship with Paul can provide support for me as the therapist in realising Pauls intensely held anticipations of embarrassment. However, I also need to be mindful of potential countertransference which could occur within my relationship with Paul which had the potential to activate automatic thoughts and schemas within me as the therapist and these cognitions have the potential for influencing the therapy process (Vyskocilova et al 2015).
As one of the principles of delivering CBT is that it is time-specific I was aware from the commencement of therapy that managing the process towards the ending of therapy was an important undertaking. Sanders and Wills (2005) perceive that therapy mostly concludes when the apportioned number of sessions is completed and, preferably, the client has realised the goals they initially identified for themselves. End-of-treatment planning began with Paul at the first session when Paul was given some indication of the frequency and duration of treatment. Working towards the end of treatment with Paul was an on-going process, ending in the final sessions with a review of the treatment and introduction of relapse-prevention skills which were undertaken in the final few sessions. My ability as a therapist to manage the therapeutic ending with Paul is deemed by Roth and Pilling (2007) as a core competency in the practice of cognitive behaviour therapy.
As the preparation for the end-of-treatment was a collaborative process, in terms of preparing Paul and assessing his readiness for ending treatment, it was also important to be aware of his ability to apply the skills he had learn over the process to the situations which arose. A key principal within the principles of CBT was that Paul would be able to undertake and apply the skills he had learnt as though he was a therapist for himself. In planning the ending of our sessions this allowed Paul the opportunity to prepare for the end of treatment, to review the skills he had learned in treatment, and to articulate and problem-solve concerns about his ability to manage outside treatment. All these factors would help to reduce his anxiety and alleviate fears that Paul might have about ending the therapeutic relationship (Cully and Teten 2008).
The importance of undertaking relapse prevention work with Paul was established by conducting this work over a number of sessions. If relapse prevention is omitted until the final session it diminishes its significance and this has a correlating impact on the learning opportunity for Paul (Chigwedere et al 2011). It was important that Paul could develop skills and strategies which he could employ to manage and neutralise any lapses he experienced before these escalated into a full relapse of his symptoms and behaviours (Grant et al 2005).
The final session with Paul was used to review and record the different cognitive and behavioral skills that he had learned. The use of Socratic questioning was used to elicit this list -“What have you learned as a result of our time together?. Paul had a list of these skills that he could use in the future however, it was important not to introduce any new concepts as this may have impacted on the cessation of treatment.
Paul attended two follow-up sessions after the completion of formal treatment, with the first session occurring approximately 1 month after treatment and the second session occurring approximately 3 months after treatment. During these sessions with Paul identified his self-management of any symptoms and stressors and this provided an opportunity to refresh skills that he had previously learned in therapy.
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